Form 2818 "Critical Incident Report" - Texas

What Is Form 2818?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 2818 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 2818 "Critical Incident Report" - Texas

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Form 2818
August 2020-E
Residential Treatment Center (RTC) Relinquishment Avoidance Project
Critical Incident Report
Instructions: Employees use this form to collect all required information when a youth sustains an injury, at the onset of an illness or for a
reportable incident. The employee who observes the incident completes and signs the form and notifies the youth’s parent or legally authorized
representative (LAR) immediately.
Note: Formal notification must also be provided to Texas Health and Human Services Commission (HHSC), the Local Mental Health Authority
(LMHA) or Local Behavioral Health Authority (LBHA), and the parent or LAR within 24 hours of the incident or injury. For additional information
on reportable incidents, refer to the RTC Project policy manual or contact rtcproject@hhsc.state.tx.us.
General Information
Youth's Full Name:
Clinical Management for Behavioral Health Services (CMBHS) ID:
Youth's Date of Birth:
Medicaid ID:
Facility Name:
Facility Physical Location:
Current Location of Youth:
Note: If the youth is in a hospital, detention or other off-campus setting, contact information must be provided.
Contact Name:
Contact Information:
Incident Information
Date of Incident:
Time of Incident:
Location of Incident:
Location Type:
If other location type, provide location details:
Child Care Licensing notified, if required: ..............................................................
Yes
No
Date of Notification:
Department of Family and Protective Services (DFPS) Statewide Intake notified,
Yes
No
if required: ..............................................................................................................
Date of Notification:
LMHA or LBHA notified: .........................................................................................
Yes
No
Date of Notification:
Parent or LAR notified: ...........................................................................................
Yes
No
Date of Notification:
Parent or LAR Name:
Area Code and Phone No.:
Parent or LAR notified by:
Phone Call
Email
Text
In Person
Other
Did parent or LAR acknowledge receipt of notification? (For example, answered phone, responded to email or text.)
Yes
No
Provide notification details, such as whether a voicemail was left if parent or LAR did not answer the phone:
Incident Details
Date Facility Staff Notified of Incident:
Incident Type (Check all that apply):
Death
Accidental
Homicide
Suicide
Unknown
Other:
Form 2818
August 2020-E
Residential Treatment Center (RTC) Relinquishment Avoidance Project
Critical Incident Report
Instructions: Employees use this form to collect all required information when a youth sustains an injury, at the onset of an illness or for a
reportable incident. The employee who observes the incident completes and signs the form and notifies the youth’s parent or legally authorized
representative (LAR) immediately.
Note: Formal notification must also be provided to Texas Health and Human Services Commission (HHSC), the Local Mental Health Authority
(LMHA) or Local Behavioral Health Authority (LBHA), and the parent or LAR within 24 hours of the incident or injury. For additional information
on reportable incidents, refer to the RTC Project policy manual or contact rtcproject@hhsc.state.tx.us.
General Information
Youth's Full Name:
Clinical Management for Behavioral Health Services (CMBHS) ID:
Youth's Date of Birth:
Medicaid ID:
Facility Name:
Facility Physical Location:
Current Location of Youth:
Note: If the youth is in a hospital, detention or other off-campus setting, contact information must be provided.
Contact Name:
Contact Information:
Incident Information
Date of Incident:
Time of Incident:
Location of Incident:
Location Type:
If other location type, provide location details:
Child Care Licensing notified, if required: ..............................................................
Yes
No
Date of Notification:
Department of Family and Protective Services (DFPS) Statewide Intake notified,
Yes
No
if required: ..............................................................................................................
Date of Notification:
LMHA or LBHA notified: .........................................................................................
Yes
No
Date of Notification:
Parent or LAR notified: ...........................................................................................
Yes
No
Date of Notification:
Parent or LAR Name:
Area Code and Phone No.:
Parent or LAR notified by:
Phone Call
Email
Text
In Person
Other
Did parent or LAR acknowledge receipt of notification? (For example, answered phone, responded to email or text.)
Yes
No
Provide notification details, such as whether a voicemail was left if parent or LAR did not answer the phone:
Incident Details
Date Facility Staff Notified of Incident:
Incident Type (Check all that apply):
Death
Accidental
Homicide
Suicide
Unknown
Other:
Form 2818
Page 2 / 08-2020-E
Allegation of Abuse
Sexual Abuse
Physical Abuse
Emotional
Source of Alleged Abuse:
Self
Family Member
Facility Staff
Another Youth at Facility
Other:
Allegation of Mistreatment or Neglect
Self Neglect
Medical Neglect
Environmental Neglect
Source of Alleged Neglect:
Self
Family Member
Facility Staff
Another Youth at Facility
Other:
Exploitation
Source of Alleged Exploitation:
Family Member
Facility Staff
Another Youth at Facility
Other:
Severe Illness, Physical Injury or Medical Emergency requiring medical intervention, call to 9-1-1 or emergency medical services resulting
in hospitalization
Medication Management Issues
Self Administered
Administered by Other
Medication Omission
Wrong Dosage
Wrong Medication
Wrong Method of Administration
Medication Refused
Noncompliance
Missed Dosage
Wrong Time (Greater than one hour)
Other:
Criminal Activity
Arrest or Incarceration
Victim of Crime
Crime Committed
Theft or Property Damage
Psychiatric or Behavioral Health Emergency requiring medical intervention, call to 9-1-1 or emergency medical services resulting in
hospitalization. Psychiatric or behavioral health emergency due to:
Serious Escalating or Aggressive Behavior Towards Others
Suicidal Ideations
Threat or Harm to Self
Suicide Attempt
Hallucinations
Other:
Restraint
Physical Hold
Chemical (i.e., use of medication or drugs)
Mechanical (i.e., use of restrictive device such as restraint belts or vests)
Elopement or Missing Youth
Parental Relinquishment
Other Risk of Harm (to self or others)
Form 2818
Page 3 / 08-2020-E
Incident Report Numbers
Police Report Number:
DFPS Report Number:
Incident Description
Describe the incident related to the child, including any staff present or other witnesses:
Provide information about other individuals involved in the incident, including any staff present or other witnesses:
Intervention and/or Action Taken to Secure Child’s Safety and Proposed Prevention Plan
Team Meeting
Update to Crisis and/or Safety Plan
Emergency Medical Treatment
Crisis Response
Emergency Department
Notification to Parent or LAR, Family Member or Guardian
Incarceration
Detention
Jail
Discharge from Facility
Placement in Treatment Facility
Psychiatric Hospitalization
Drug/Alcohol Treatment Facility
Medical Hospital
Signature of Staff Completing Form
Printed Name:
Title:
Signature:
Date:
Area Code and Phone No.:
HHSC Review (For HHSC Use Only)
Date Received:
HHSC Summary of Review:
Parental Notification Confirmed
Yes
No
Follow-up Required
Yes
No
HHSC Reviewer:
Review Date:
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