Critical Incident Reporting Form - Minnesota

This "Critical Incident Reporting Form" is a part of the paperwork released by the Minnesota Corrections Department specifically for Minnesota residents.

The latest fillable version of the document was released on October 1, 2005 and can be downloaded through the link below or found through the department's forms library.

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Critical Incident Reporting Form
NONPUBLIC FILE
DOC USE ONLY
_________
ID#
DHS LICENSE ___________________
Within 10 days of the incident, submit one copy of this form with any attachments to your licensor:
Please print
Facility Name (
)
Telephone Number
Date of Report
(__ __ __) __ __ __ - __ __ __ __
__ __ / __ __ / __ __
Please print)
Facility Address (
Date of Incident
Time
__ __ / __ __ / __ __
__ __ __ __
(Please print
(Please
Facility Administrator (Last, First,)
)
Resident/offender(s) Involved (Last, First, Middle Name)
print)
Please print)
Person Reporting (Last, First) (Please print)
Staff Involved (Last, First,) (
Please print
Person in Charge During Incident (Last, First) (
)
Last Logged Check of Resident(s) Involved:
Date:
__ __ / __ __ / __ __
Time:
__ __ __ __
Findings:
Incident Type
(Circle One)
(See Definitions on Back)
m. Sexual Misconduct
f. Fire
a. Suicide *
i. Escape from a secure facility
1. Resident on Resident by coercion
b. Homicide *
g. Riot/Disturbance
j. Serious Resident Injury
2. Resident on Resident - mutual consent
h. Assault
c. Other Death (Identify) *
k. Serious Resident Illness
3. Resident on Staff
1. Resident on Resident
d. Attempted Suicide *
l. Serious Infectious Disease
4. Staff on Resident
2. Resident on Staff
e. Natural Disaster
n. Alleged Maltreatment
3. Staff on Resident
o. Other
(Identify Below)
* Attach Attempted Suicide/Suicide/Non-Suicide Death Survey Form
(DOC FACILITIES ONLY)
Other:
Attachments: __ Yes __ No # of pages: ___
Summary of Incident or attach related reports
PLEASE NOTE:
Notifying your licensing agency on this critical incident report does not take the place of your mandatory
reporting responsibility.
Subp. 24. Critical incident. “Critical incident” means an occurrence, which involves a resident and requires the program
to make a response that is not a part of the program’s ordinary daily routine. Examples of critical incidents include, but are
not limited to, suicide, attempted suicide, homicide, death of a resident, injury that is either life-threatening or requires
medical treatment, fire which requires fire department response, alleged maltreatment of a resident, assault of a resident,
assault by a resident, client-to-client sexual contact, or other act or situation which would require a response by law
enforcement, the fire department, an ambulance, or another emergency response provider.
This form may be copied as needed.
Revised 10/01/05
Side 1 of 2
Critical Incident Reporting Form
NONPUBLIC FILE
DOC USE ONLY
_________
ID#
DHS LICENSE ___________________
Within 10 days of the incident, submit one copy of this form with any attachments to your licensor:
Please print
Facility Name (
)
Telephone Number
Date of Report
(__ __ __) __ __ __ - __ __ __ __
__ __ / __ __ / __ __
Please print)
Facility Address (
Date of Incident
Time
__ __ / __ __ / __ __
__ __ __ __
(Please print
(Please
Facility Administrator (Last, First,)
)
Resident/offender(s) Involved (Last, First, Middle Name)
print)
Please print)
Person Reporting (Last, First) (Please print)
Staff Involved (Last, First,) (
Please print
Person in Charge During Incident (Last, First) (
)
Last Logged Check of Resident(s) Involved:
Date:
__ __ / __ __ / __ __
Time:
__ __ __ __
Findings:
Incident Type
(Circle One)
(See Definitions on Back)
m. Sexual Misconduct
f. Fire
a. Suicide *
i. Escape from a secure facility
1. Resident on Resident by coercion
b. Homicide *
g. Riot/Disturbance
j. Serious Resident Injury
2. Resident on Resident - mutual consent
h. Assault
c. Other Death (Identify) *
k. Serious Resident Illness
3. Resident on Staff
1. Resident on Resident
d. Attempted Suicide *
l. Serious Infectious Disease
4. Staff on Resident
2. Resident on Staff
e. Natural Disaster
n. Alleged Maltreatment
3. Staff on Resident
o. Other
(Identify Below)
* Attach Attempted Suicide/Suicide/Non-Suicide Death Survey Form
(DOC FACILITIES ONLY)
Other:
Attachments: __ Yes __ No # of pages: ___
Summary of Incident or attach related reports
PLEASE NOTE:
Notifying your licensing agency on this critical incident report does not take the place of your mandatory
reporting responsibility.
Subp. 24. Critical incident. “Critical incident” means an occurrence, which involves a resident and requires the program
to make a response that is not a part of the program’s ordinary daily routine. Examples of critical incidents include, but are
not limited to, suicide, attempted suicide, homicide, death of a resident, injury that is either life-threatening or requires
medical treatment, fire which requires fire department response, alleged maltreatment of a resident, assault of a resident,
assault by a resident, client-to-client sexual contact, or other act or situation which would require a response by law
enforcement, the fire department, an ambulance, or another emergency response provider.
This form may be copied as needed.
Revised 10/01/05
Side 1 of 2
Critical Incident Reporting Form
The definitions for the types of incident are provided below. These definitions are offered as a guide only. If you
NOTE:
have any questions, please contact the inspector assigned to your facility.
Incident Definitions
SUICIDE:
Intentionally killing oneself.
HOMICIDE:
The killing of one person by another.
OTHER DEATH:
Accidental death or death from natural causes.
ATTEMPTED SUICIDE:
The attempt to intentionally kill oneself, and the attempt caused injury or could have
resulted in serious injury or death if not detected.
NATURAL DISASTER:
Acts of nature which cause personal injury to staff and/or residents or which causes
structural damage to the physical plant.
FIRE:
Incidents of fire resulting in the response by a local fire authority, requiring medical
treatment of staff or residents, or significantly threatens the security of the facility.
RIOT:
Any disturbance by three or more residents that seriously disturbs the operation of a
facility, jeopardizes the control of an area, threatens violence against or destruction of
property, or results in significant property damage or personal injury to residents or
staff.
SERIOUS INFECTIOUS DISEASE:
Diseases such as but not limited to TB, Hepatitis A, B, or C, or serious sexually
transmitted diseases as tracked by the Center for Disease Control. This only needs to be
reported if there is a threat of transmission of the disease to staff or other residents.
SERIOUS RESIDENT INJURY:
Any injury to a resident that requires the resident to be hospitalized or receive significant
medical treatment. Significant medical treatment is treatment that could not be handled
by a trained health care person in a non-clinic setting.
SERIOUS RESIDENT ILLNESS:
Any resident illness that requires the resident to be hospitalized or receive significant
medical treatment except 72-hour mental health holds and detoxification holds
– DOC only. Significant medical treatment is treatment that could not be handled by a
trained health care person in a non-clinic setting.
ASSAULT:
An act committed by a resident or a staff /volunteer on another resident or staff
/volunteer that results in physical harm and that requires significant medical care.
Significant medical treatment is treatment that could not be handled by a trained health
care person in a non-clinic setting
(Harm resulting from sexual misconduct or assault is to be separately reported.)
SEXUAL MISCONDUCT:
Any sexual conduct between residents or between residents and staff / volunteers.
Sexual conduct includes intentional touching of another person’s intimate parts, or the
clothing covering the immediate area of the intimate parts, committed with sexual or
aggressive intent
ESCAPE:
A resident’s departure from a secure facility without lawful authority. This includes both
juvenile and adult facilities. This also includes escapes while on a supervised off grounds
setting ( i.e. transports, hospital, medical visits). STS should be reported on Special
Incident Quarterly Reporting form.
OTHER:
Incidents not reported in another category that result in a child protection investigation,
significant media coverage or juvenile/adult charged with a crime.
This form may be copied as needed.
Revised 10/01/05
Side 2 of 2

Download Critical Incident Reporting Form - Minnesota

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