Please check type of incident

Incident Involving Injury

Suicide Attempt

Death of Client

Medication Error

Infection Control/Communicable Diseases

Acts of Aggression/Violence

Use/Possession Unauthorized Weapon

Use of seclusion or restraint

Wandering or elopement

Bio-hazardous Accidents

Unauthorized use/possesion of legal or illegal substances on site

Abuse, Neglect, Sexual Assault

Overdose

Client Arrest and/or Incarceration

Other Sentinel Events: Incidents that result in a client's death or a serious physical or psychological injury.

Psychiatric Inpatient Evaluation and/or Hospitalization

Date Incident Discovered *

MM

DD

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Name of Client Involved *

First Name

Last Name

Staff Member Submitting Report

First Name

Last Name

Date Reported to Critical Incident Officer

MM

DD

YYYY