CRITICAL INCIDENT REPORT

PAGE 1

Quality/Compliance Use Only
SF
3200 scanned
DT High Low
JZ
Staff Injury to NS
Auto Accident to DS
IRPM compl.
N180 CIR compl.

D. A. BLODGETT – ST. JOHN’S

CRITICAL INCIDENT REPORT

A. PROGRAM:
Date: / Time: / Place:
Name of person completing this CIR:
Position of person completing this CIR:
(social worker, therapist, case aide, foster parent, etc.)

B. Type of Incident:

Behavioral Acting out by Child

Accidental Injury to Child

Injury to child caused by self-harm, harm by another or during physical management

Significant injury to child requiring medical attention

Child Alcohol/Drug use

Child Community Offense

AWOL/ Run Away/ Police Report

Call for Police/Fire or EMT

Physical Confrontation or use of restraint/discipline

(Parent must be notified if Physical Management is utilized)

Property Damage

Staff Injury(attach Staff Injury Report Form)

Staff Auto Accident (attach Auto Accident Form)

Medication Error

CPS Referral

Other:

C. Client (Child) involved in incident:

First name: / Last name: / Age: / DOB:
First name: / Last name: / Age: / DOB:
First name: / Last name: / Age: / DOB:

D. Others involved in incident and role: (foster parent, worker, therapist, etc.)

First name: / Last name: / Role:
First name: / Last name: / Role:
First name: / Last name: / Role:

E. Description of incident(s):

  1. Describe what happened; include events leading up to incident:

  1. Action Taken:

3. Persons notified:

Name: / Date: / Time:
Name: / Date: / Time:
Name: / Date: / Time:

F. Follow up CIR required?(Residential, KidsFirst, and STEP programs only) Yes No

G. Referrals made: (attach documentation)CPS Yes No

DCWL Yes No

H. Initiated Internal Special Investigation of Licensed Foster Home? Yes No

DCWL Notified of this investigation

I. Incident Entered into MISACWIS Yes No

Incident Report was received and reviewed by: (Please print)

Date:
Reported By (mandatory) / (KidsFirst, Residential, STEP – by end of shift)
(All Others - within 3 calendar days of incident)
Date:
Care Provider (Foster Parent, Adoptive Parent, Licensed Relative or Legal Parent or Volunteer)
Date:
Social Worker
Date:
Nurse
Date:
Licensing Supervisor (if applicable)
Date:
Supervisor, Team Lead, House Manager (mandatory)
Date:
Program Manager or Program Coordinator (mandatory)
Date:
Program Director (mandatory)
Date:
Recipient Rights Advisor (when incident includes a potential Rights Violation)

O:\Agency General Documents, Procedures, and Forms\GENERAL FORMS\CRITICAL INCIDENT REPORT FORM.docx;

revised - 2/22; 4/7; 7/21/10; 2/2011; 6/29/11; 11/27/12; 4/29/13; 7/28/14; 4/29/15; 10/5/2016; 3/2017