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Licensing-Critical & Other Incident Reporting Form
Facility Name
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License Number
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Type of Incident
Injury Sustained While in Seclusion or During Restraint
Unplanned Hospitalization
Suicide Attempt
Elopement
Unexplained Absence
Use of Chemical Agent
Other
Please select at least one option
Date of Incident
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Time of Incident
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Resident(s) Involved in Incident
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Staff Involved in Incident or Present at the Time of Incident
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Description of Incident
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Action Taken as Result of Incident
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Person(s) who witnessed incident
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Incident Also Reported To:
Child Welfare Placement Worker or Centralized Intake Hotline
Office of Juvenile Justice
Law Enforcement
Parent/Legal Guardian
Other
Please select at least one option
Select all applicable
List name(s) of individuals reported to if "other" is selected above.
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Name of Staff Reporting Incident
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Name of Staff Completing Report
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Date of Completion
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To print this form before hitting "Submit". Return to top right of page and right click your mouse and select the "Print" option in order to print a copy of the Incident Report for your records.
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