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Critical Incident Report Form - Louisiana Department of Health and - dhh state la

Critical Incident Report Form - Louisiana Department of Health and - dhh state la 2025

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The document is a Critical Incident Report Form from the Office of Aging and Adult Services (OAAS) under the Department of Health and Hospitals. It is designed for reporting incidents involving participants in Home and Community Based Services (HCBS), including details about the participant, incident categories, event information, and follow-up actions. The form emphasizes the importance of reporting abuse, neglect, exploitation, and other critical incidents to appropriate authorities.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'Participant Identifying Information' section. Enter the participant's first, middle (if known), and last name, along with their address, city, state, telephone number, region, date of birth (DOB), social security number (SSN), parish, and gender.
Next, complete the 'Incident Categories' section by checking all applicable boxes related to the incident. Ensure you include any protective services allegations that need immediate verbal reporting.
In the 'Event Information' section, provide details about when and where the incident occurred. Include dates and times for both when the incident happened and when it was discovered.
Describe the critical incident in detail in the 'Critical Incident Description' section. Be thorough in documenting specifics such as who was involved and any follow-up actions taken.

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2014	4.8 Satisfied (101 Votes)
2010	4.3 Satisfied (58 Votes)

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What is the critical incident reporting form?

Critical incident reporting metrics are designed to measure the events that have the most potential to be psychologically traumatizing for first responders and are closest linked to PTSD and suicide.

What is the purpose of critical incident reporting?

Examples of a critical incidents in the workplace include a death or severe injury of a member, a fire, a bomb threat, or an armed hold-up. People who witness a critical incident may suffer from distress and poor emotional well-being moving forward. This may last a few hours or many months.

How do I create an incident report form?

How to Write an Incident Report: A Step-by-Step Guide (with Examples) Step 1: Provide Fundamental Information. Step 2: Take Note of Any Damages and Injuries. Step 3: Identify Affected Individual(s) Step 4: Identify Witnesses and Take Their Statements. Step 5: Take Action. Step 6: Close Your Report.

How to complete an incident report form?

The Health and Safety Executive specifies that the following must be reported: Deaths and injuries caused by workplace accidents. Occupational diseases. Carcinogens mutagens and biological agents.

What is a critical incident reporting form?

How to write a workplace incident report Gather essential information. Describe the incident. Include injuries and damages. Interview witnesses. Identify contributing factors. Review company policies and procedures. Attach supporting documents. Maintain objectivity.