Critical Incidents Reporting Form

CRITICAL INCIDENT REPORTING FORM

FOR ALL UNLICENSED PROGRAMS AND FOR LICENSED FACILITIES TO REPORT USE OF RESTRAINT THAT IS NOT REPORTABLE TO LICENSING
This is not to replace the CLBC form that will be submitted to CLBC, but rather for staff collecting the data and properly recording the information required for. The CLBC form (as previewed below) will be completed by the Health & Safety Coordinator (HSC) on your behalf based on the information provided on this form.

If you have any questions completeing the form, please reach out to Fraser the HSC at safety@pandoraservicesbc.com or 604-262-6230.

For more support is our guide to how to complete a CIR "How to Write at CIR":

Critical Incidents Reporting (CIR) - How to Report Section

https://www.pandoraservicesbc.com/health-safety
GENERAL INFORMATION
Name of Program / Place of Service
Found In Humi Client Project
Organization Phone Number
Address*

18810 72 Avenue

Unit 205

SurreyBC

V4N 6R4
Name of Service Provider
Pandora Services Inc
Service Category (reference CLBC contract)
Found In Humi Client Project Starting with 315xxxx
Category*

LicensedNot Licensed
PEOPLE INVOLVED (one Individual per form)
People Involved (one Individual per form)*

IndividualVisitorOther (please specify)
Name of Individual involved*
Birthdate (MM/DD/YYYY)

MonthDayYear
Date
List All Persons Adversely Affected (attached list if necessary)*
TYPE OF INCIDENT - REPORTABLE TO CLBC

one per form
ABUSE

Emotional AbuseFinancial AbusePhysical AbuseSexual AbuseNeglect
Restricted Practices

RestraintRestriction of Rights
Other Incident Types

Aggression Between IndividualsAggressive / Unusual BehaviourAttempted SuicideChokingDeathDisease / Parasite OutbreakFallMedication ErrorMissing / WanderingMisuse of Illicit Drugs or Licit DrugsMotor Vehicle InjuryOther InjuryPoisoningService Delivery Problem/Disruption of ServiceUnexpected Illness/Food PoisoningUse of SeclusionWeapon Use
DETAILS OF INCIDENT
Date of Incident*

MonthDayYear
Date
Time of Incident (24 hh:mm)*

Hour Minutes
Location of Incident*
What occurred? (attach additional page if required)*
Actions taken (attach additional page if required)*
NOTIFICATION

Parties Notified*

	Y/N	Name of Person Contacted	Relationship to Individual or Position Title	Date	Time	Contact Phone Number
Family / Member / Representative
Program Supervisor / Manager
Health Care Provider
Public Guardian Trustee
Fire Department
Police
Ambulance
Coroner
Other (specify):
CLBC Staff

SIGNATURES
Signature Consent*

By checking this box, you are consenting to use your signature to sign off on the formal CLBC Critical Incident Report Form
Signature*

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Email of Reporting Manager / Supervisor*

FOR INTERNAL OFFICE USE: HEALTH & SAFETY (HSC)
FOLLOW-UP REQUESTED

To be completed by our Quality Assurance Coordinator
Follow-Up Requested

DebriefingSafety Issues To Be AddressedForward to Health & Safety CommitteeNo Follow-Up RequiredOther
Follow Up Action Plan (i.e. Necessary Education/Training, Prevention of Reoccurance & Quality Improvement):
Supervisor/Person who Followed Up

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Date

MonthDayYear
Date
Should be Empty:

CRITICAL INCIDENT REPORTING FORM

GENERAL INFORMATION

PEOPLE INVOLVED (one Individual per form)

TYPE OF INCIDENT - REPORTABLE TO CLBC

DETAILS OF INCIDENT

NOTIFICATION

SIGNATURES

FOLLOW-UP REQUESTED