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Licensing-Critical & Other Incident Reporting Form

Facility Name

License Number

Type of Incident

Injury Sustained While in Seclusion or During Restraint Unplanned Hospitalization Suicide Attempt Elopement Unexplained Absence Use of Chemical Agent Other

Date of Incident

Time of Incident

Resident(s) Involved in Incident

Staff Involved in Incident or Present at the Time of Incident

Description of Incident

Action Taken as Result of Incident

Person(s) who witnessed incident

Incident Also Reported To:

Child Welfare Placement Worker or Centralized Intake Hotline Office of Juvenile Justice Law Enforcement Parent/Legal Guardian Other

Select all applicable

List name(s) of individuals reported to if "other" is selected above.

Name of Staff Reporting Incident

Name of Staff Completing Report

Date of Completion

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.