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    Critical Incident Report Form

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    jirehcounseling
    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Critical Incident Report Form

    Uploaded by

    jirehcounseling
    372 views3 pages
    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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    critical incident report form

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    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    372 views3 pages

    Critical Incident Report Form

    Uploaded by

    jirehcounseling
    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.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3

    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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