CRITICAL INCIDENT FORM by HC121117122441

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									                                              D. A. BLODGETT – ST. JOHN’S
                                              CRITICAL INCIDENT REPORT
A. Agency Program Involved:
   Date:                                                Time:                                      Place:

B. Type of Incident: (check one or more)                        Injury to Child
         Behavioral Acting Out by Child                        Significant Physical Injury
         Minor Accidental Injury                               Alcohol/Drug Abuse
         AWOL/Run Away/Police Report                           Property Damage
         Call for Police/Fire or EMT Personnel                 Community Offense
         Physical Confrontation or use of restraint/discipline (Note: parent must be notified if physical restraint is utilized)
         Staff Injury
         Medication Error (attach medication incident addendum)
         Other

C. Name of Person(s) involved:
   List each child involved and their ages/dates of birth:



                                       PLEASE USE REVERSE SIDE FOR ADDITIONAL SPACE
D. Description of incident(s):

         1. Events leading to incident:




         2. What happened:




         3. Action taken and reason/persons notified:




E. Follow up CIR required?                     Yes              No

F. Referrals made: (attach documentation)  CPS                  BCAL (Special Investigation)

G. Internal Investigation Initiated?           Yes              No

H. Signatures:
                                                                                          Date
         Reported By                                                                      (within 3 calendar days of incident)

                                                                                        Date
         House Manager, Foster, Adoptive, Licensed Relative or Legal Parent or Volunteer’s Signature (if applicable)

                                                                                          Date Completed
         Social Worker’s Signature

                                                                                 _______Date Completed
         Licensing Supervisor Signature

                                                                                          Date Completed
         Supervisor's Signature

                                                                                          Date Completed
         Program Manager's Signature

                                                                                          Date Completed
         Program Director's Signature

                                                                                          Date
         Recipient Rights Advisor’s Signature (if applicable)
CRITICAL INCIDENT REPORT
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                                                  CONTINUED FROM PAGE 1



      1. Events leading to incident:




      2. What happened:




      3. Action taken and reason:




      cc: Child’s file; CIR file       O:\Admin-Management Policy\CRITICAL INCIDENT FORM.doc; 2/22; 4/7; 7/21/10; 2/2011

								
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