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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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