Critical Incident Reporting Form
ADVERTISEMENT
1
2Critical Incident Reporting Form
NONPUBLIC FILE
DOC USE ONLY
_________
ID#
DHS LICENSE ___________________
Within 10 days of the incident, submit one copy of this form with any attachments to your licensor:
Please print
Facility Name (
)
Telephone Number
Date of Report
(__ __ __) __ __ __ - __ __ __ __
__ __ / __ __ / __ __
Please print)
Facility Address (
Date of Incident
Time
__ __ / __ __ / __ __
__ __ __ __
(Please print
(Please
Facility Administrator (Last, First,)
)
Resident/offender(s) Involved (Last, First, Middle Name)
print)
Please print)
Person Reporting (Last, First) (Please print)
Staff Involved (Last, First,) (
Please print
Person in Charge During Incident (Last, First) (
)
Last Logged Check of Resident(s) Involved:
Date:
__ __ / __ __ / __ __
Time:
__ __ __ __
Findings:
Incident Type
(Circle One)
(See Definitions on Back)
m. Sexual Misconduct
f. Fire
a. Suicide *
i. Escape from a secure facility
1. Resident on Resident by coercion
b. Homicide *
g. Riot/Disturbance
j. Serious Resident Injury
2. Resident on Resident - mutual consent
h. Assault
c. Other Death (Identify) *
k. Serious Resident Illness
3. Resident on Staff
1. Resident on Resident
d. Attempted Suicide *
l. Serious Infectious Disease
4. Staff on Resident
2. Resident on Staff
e. Natural Disaster
n. Alleged Maltreatment
3. Staff on Resident
o. Other
(Identify Below)
* Attach Attempted Suicide/Suicide/Non-Suicide Death Survey Form
(DOC FACILITIES ONLY)
Other:
Attachments: __ Yes __ No # of pages: ___
Summary of Incident or attach related reports
PLEASE NOTE:
Notifying your licensing agency on this critical incident report does not take the place of your mandatory
reporting responsibility.
Subp. 24. Critical incident. “Critical incident” means an occurrence, which involves a resident and requires the program
to make a response that is not a part of the program’s ordinary daily routine. Examples of critical incidents include, but are
not limited to, suicide, attempted suicide, homicide, death of a resident, injury that is either life-threatening or requires
medical treatment, fire which requires fire department response, alleged maltreatment of a resident, assault of a resident,
assault by a resident, client-to-client sexual contact, or other act or situation which would require a response by law
enforcement, the fire department, an ambulance, or another emergency response provider.
This form may be copied as needed.
Revised 10/01/05
Side 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business