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Critical Incident Report Form (PDF) - dhs mn 2026

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The document outlines the procedures for reporting critical incidents in Intensive Residential Treatment Programs, including the requirement to submit a Critical Incident Reporting Form to the licensing agency within 10 days of an incident. It specifies various types of incidents that must be reported, such as suicides, assaults, and injuries requiring medical attention. Additionally, it emphasizes the importance of maintaining records for review and conducting a quality assurance review of the incident response.

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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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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (154 Votes)
2013	4.1 Satisfied (44 Votes)
2010	4.7 Satisfied (39 Votes)

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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.

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?

An incident report is a formal document that records accidents, injuries, near misses, and other unexpected events in a workplace. It provides a detailed account of the incident or accident, including where and when it happened, who was involved, and any contributing factors.

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.