DMHAS CRITICAL INCIDENT SUBMISSION FORM Mental Health PNP Affiliates : Submit this form to designated contact at your LMHA. PNP/State Operated LMHAs and Addiction Service Providers : Use this form to guide data entry into the online Critical Incident Application. The Incident Contact Person: Contact Phone: Date of Incident: Time of Incident: Location of Incident (CT Town Name or Out of State): Location Type (Check one): DMHAS Critical Incident Form – rev. 11/08/2018 page 1
Client’s Residence Community (public location, relative’s home, etc.) IP Unit, DMHAS-Op IP Unit, Non-DMHAS Jail Nursing Home Program Premises: Non-Inpatient Other Location (please specify) : Incident Category/Subcategory (check only one box to indicate a category type for this incident). Client Abuse Physical Abuse Verbal Abuse Sexual Abuse Neglect Exploitation Patient Rights Violation of patient rights with significant consequences Breach of confidentiality with significant consequences Death Suicide Homicide Accident Accidental Overdose (resulting in death) Medical Error Illness, Age, or Medical Reason Info Pending / Insufficient Info Emergency Evacuation Fire Bomb Other Escape (Forensic only) PSRB DOC Competency Restoration Federal Notification Secret Service FBI Other Federal Notice Medical Event Accidental Injury Accidental Overdose (not resulting in death) Medication Error/Reaction Medical Event – Other Missing Client Missing Inpatient, Risk to Self or Others Missing Outpatient, Risk to Self or Others Missing Person Property Damage Property Damage – Safety Issue Property Damage Serious Crime Physical Assault Sexual Assault Risk of Injury to Minor Arson Firearms Hostage Drug Sale / Distribution/Possession Homicide / Manslaughter Theft/Burglary Other Serious Crime (specify): Serious Suicide Attempt Suicide Attempt while Active in Program Suicide Attempt within 30 days of Discharge Threats Threats to Agency Threats to Person Other Other Incident (specify):
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- Spring '07
- assault, Barbiturate