Critical Incident Report Form (PDF) - dhs mn 2025

1. Click ‘Get Form’ to open the Critical Incident Report Form in the editor.
2. Begin by entering the Facility’s License Number and Facility Name at the top of the form. Ensure that all information is printed clearly.
3. Fill in the Telephone Number and Facility Address, making sure to provide accurate contact details for follow-up.
4. Record the Date of Incident and Date of Report. Use the format provided to avoid any confusion.
5. Indicate the Time of the incident using a 24-hour clock format for clarity.
6. Complete the Treatment Director's name, followed by details of Recipient(s) Involved and Person Reporting. Ensure all names are printed clearly.
7. List Staff Involved and circle the appropriate Incident Type from the options provided, ensuring you select all that apply.
8. Indicate if there are any attachments related to this report and summarize the incident in detail, or attach related reports as necessary.
9. Finally, complete sections for QA Review including data reviewed, policies followed, and any comments before submitting your report.

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