Attachment 7 Critical Incident Report.pdf

The document is a Critical Incident Report form (Attachment 7) designed for documenting serious events or incidents in a care or service environment. The form provides a comprehensive template for recording detailed information about critical incidents, including the type of incident, location, client details, staff involvement, and a structured approach to reporting and follow-up.

The report form includes sections for describing the incident, precipitating factors, behavior management techniques used, and follow-up actions. It also includes a notification matrix for documenting communications with internal staff, referring agencies, parents/guardians, regulatory agencies, and law enforcement. The form requires signatures from the person completing the report, a clinical reviewer, an administrative reviewer, and potentially a program director, with specific review criteria focused on comprehensiveness, relevance, notification procedures, and timeliness of actions taken.