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Critical Incident Report Form (PDF) - dhs mn 2026
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- Click ‘Get Form’ to open the Critical Incident Report Form in the editor.
- Begin by filling in the Facility’s License Number, Facility Name, and Telephone Number. Ensure that all information is printed clearly for easy readability.
- Enter the Date of Incident and Date of Report using the provided format. This helps maintain accurate records.
- Document the Time of the incident accurately. This is crucial for reporting purposes.
- Fill in the Treatment Director's name, along with details of Recipient(s) Involved and Person Reporting. Make sure to include last names and first names as required.
- Indicate the Incident Type by circling all applicable options. This section is vital for categorizing the nature of the incident.
- If there are any attachments, mark 'Yes' or 'No' and specify the number of pages attached.
- Provide a detailed Summary of Incident or attach related reports to give context to your submission.
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dhs reportable incident form
Several different types of reports are collected from providers, counties and others in the system. Those reports include: DHS. Incident-Licensure, DD ProgramRead more
Critical Incident Reporting Form. Instructions. Email this form to IRTS.CIR.DHS@state.mn.us within ten days of the occurrence. Multiple CIRs can be submittedRead more