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Critical Incident Report Form

This document is a critical incident report form containing sections to report details of an incident including: date of incident, location, consumer(s) information, type of incident which could be category I like death or category II, witnesses, notifications, and details if it was a death including cause and circumstances. The administrator must review and sign off on all critical incidents.

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jirehcounseling
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472 views3 pages

Critical Incident Report Form

This document is a critical incident report form containing sections to report details of an incident including: date of incident, location, consumer(s) information, type of incident which could be category I like death or category II, witnesses, notifications, and details if it was a death including cause and circumstances. The administrator must review and sign off on all critical incidents.

Uploaded by

jirehcounseling
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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CRITICAL INCIDENT REPORT FORM

Incident #
Date of Report Date of Incident/Death:

Date of Discovery of Incident/Death: Time of Incident/Death:

State Hospital reporting:


Community Provider reporting:

If reporting provider is a subcontractor, who is primary contractor?

Contact Person: Contact Person phone #:

MHDDAD Region #: Person Completing Report:

Name of site and/or specific location where incident/death occurred (i.e.: Unit name/number, name of PCH, etc):

Check appropriate box

(please specify):

Consumer(s) Information*

Name DOB Age at Time of Incident Sex

Address City State GA Zip County

Medicaid Waiver? CID # SS# Race

Admission Date Disability: Check box if consumer directed services


List agency services in which consumer is enrolled:

Extent of Injury:

Brief description of injury:

Name DOB Age at Time of Incident Sex

Address City State GA Zip County

Medicaid Waiver? CID # SS#: Race

Admission Date Disability: Check box if consumer directed services

List agency services in which consumer is enrolled:

Extent of Injury:

Brief description of injury:


CRITICAL INCIDENT REPORT FORM
Type of Incident
Category I (check all that apply) Check here if incident is high visibility
(please complete death section)

Category II (check all that apply) Check here if incident is high visibility

Brief description of incident


CRITICAL INCIDENT REPORT FORM

Witnesses to Incident

Name Contact #

Name Contact #

Name Contact #

Name Contact #

Notifications
Agency Name Date/time Method of Notification

Deaths (if applicable)


How was death discovered?

Date of last contact with consumer: Reason for contact:

Was death expected? Was death an accident?

Possible suicide? Possible Homicide?


Presence of Significant disease processes/factors in death (check all that apply)

Has autopsy been ordered If not state reason:

Cause of death, when known:

Were there unusual circumstances surrounding death? If yes, please describe below

Administrator’s Review for all critical incidents


State Hospital/Community provider staff/title:
Date:

By checking this box, I attest that the above entry for State hospital/community provider staff/title verifies my review of the
incident.

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