Critical Incident Report

1
Name of Employee Reporting Incident* This field is required.
First Name
Last Name
2
Employee's Phone Number* This field is required.
Area Code
Phone Number
3
Date/Time Critical Incident Occurred
Date
Year
Month
Day
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Minutes
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4
Date/Time Critical Incident was Discovered
Date
Year
Month
Day
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Hour
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Minutes
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PM
5
If date/time is not known above, please explain.
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6
Critical Incident Type* This field is required.
Please Select
Please Select
Witnessed or Suspected Abuse/Neglect
Witnessed or Suspected Sexual Abuse/Neglect
Theft
Financial Exploitation
Medication Error
Minor Injury
Unexpected Death
Coworker Policy Violation
7
Please list as much detail as possible about the critical incident you witnessed or suspect. Including names of all parties involved, location, and how you handled it. * This field is required.
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8
Signature* This field is required.
Should be Empty: