Relapse Incident Report Form — Roots to Recovery

R2R-ID of the resident involved *

This form is completed in respect of every suspected or confirmed relapse incident, including any positive drug or alcohol test, any refusal to test, any tampering with a sample, any observed intoxication, any overdose, and any incident in which a prohibited substance, prohibited item or drug paraphernalia is found in connection with a Resident.

This form is completed in addition to the general Incident Report Form where the incident involves wider matters such as injury, property damage or aggression.

SECTION A — INCIDENT IDENTIFICATION

Relapse Incident Reference NumberDate of IncidentTime of IncidentLocation on the Premises (or off-premises during leave)Date of Last Confirmed Sobriety Test (Negative)Days Since Admission

SECTION B — RESIDENT

Full NamesIdentity Number / Passport NumberRoom NumberDate of AdmissionPrimary Substance of Concern (on admission)Substance Suspected in this IncidentPrior Relapse Incidents During this Stay (Yes / No, dates)Responsible Person Name and Contact

SECTION C — HOW THE RELAPSE WAS IDENTIFIED

Trigger for Concern (tick all that apply)

☐ Random drug test positive result
☐ Scheduled drug test (return from leave) positive result
☐ Reasonable-suspicion test positive result
☐ Refusal to test
☐ Tampering with a sample
☐ Smell of alcohol or chemicals on the Resident
☐ Slurred speech, unsteady gait, sedation or other observed signs of intoxication
☐ Agitation, paranoia, hallucination or other psychiatric signs consistent with substance use
☐ Drug paraphernalia found
☐ Prohibited substance found in possession
☐ Disclosure by the Resident
☐ Disclosure by another Resident or visitor
☐ Disclosure by the Responsible Person
☐ Observation of off-premises conduct
☐ Other (specify)

If "Other", describe

SECTION D — OBSERVATIONS AT THE SCENE

Level of consciousness (alert / drowsy / unresponsive)BreathingPulse and skin colourSpeech (clear / slurred / incoherent)Gait and coordinationPupils (constricted / dilated / equal)Smell of alcohol or chemicalsVisible injuriesBehaviour (calm / agitated / aggressive / withdrawn / paranoid)Other observations

SECTION E — TEST CONDUCTED

Test Conducted (Yes / No)Date and Time of TestType of Test (urine / saliva / breathalyser / lab confirmation)Kit Lot Number and ExpirySubstances Tested for and Result for EachSample Sent for Laboratory Confirmation (Yes / No)Chain-of-Custody Reference (if sent to lab)Tester (Full Name)Witness (Full Name)Resident Signature Acknowledging Result

SECTION F — PROHIBITED ITEMS, SUBSTANCES OR PARAPHERNALIA FOUND

Item / Substance	Where Found	Approximate Quantity	Action Taken	Witnesses

SECTION G — IMMEDIATE ACTIONS TAKEN

Describe each action taken to safeguard the Resident, the residence and the response process. Include times.

______________________________________________________________________________________________________________

Persons notified

Facility Manager (time)Responsible Person (time)Emergency Doctor / Ambulance (time)Certified Homeopath (time)South African Police Service (time, if applicable)Other (time)

SECTION H — MEDICAL AND PSYCHIATRIC OUTCOME

Medical assessment outcomeTransported to a medical facility (Yes / No, where, when)Medication administered (if any) and by whomPsychiatric assessment outcomeTime at which Resident was deemed medically stable

SECTION I — RESIDENT ACCOUNT (DURING RELAPSE REVIEW MEETING)

Record, in the Resident's own words where possible, the Resident's account of what happened, what triggered the relapse, and what supports are needed going forward.

______________________________________________________________________________________________________________

SECTION J — RELAPSE REVIEW MEETING

Date and Time of MeetingLocation of Meeting

Attendees

Full Name	Role	Present in Person / By Phone	Signature

Summary of discussionMitigating factors consideredAggravating factors consideredMedical or psychiatric factors consideredPrior relapses or breaches considered

SECTION K — DECISION AND PLAN

Outcome (tick one)

☐ Continued residence with an updated recovery plan
☐ Suspension of privileges for a defined period
☐ Conditional continuation with referral to an external programme
☐ Short transfer to a detox or medical facility, with return
☐ Termination of admission

Reasons for the decisionConditions of continued residence (if applicable)Review date for conditionsEffective date of decisionRight of review explained to the Resident (Yes / No, who explained)

SECTION L — UPDATED RECOVERY PLAN (WHERE CONTINUED RESIDENCE)

Plan Element	Action	Owner	Review Date
Increased testing frequency
Counselling frequency
Mentorship frequency
NA / HEAL meeting attendance
Leave restrictions
Privilege restrictions
External referral
Other

SECTION M — CROSS-REFERENCES

Drug Testing Logbook referenceIncident Report Form reference (if applicable)Medication Register reference (if applicable)Personal Property Register reference (confiscated items)Disciplinary file reference

SECTION N — SIGN-OFF

Resident

Full NameSignatureDate

Responsible Person

Full NameSignatureDate

Facility Manager

Full NameSignatureDate

Counsellor / Mentor

Full NameSignatureDate

SECTION O — CLOSURE

Date follow-up completed (within 48 hours)Follow-up findingsDate of next progress reviewDate closedClosed by (Full Name)Signature