Critical Incident Reporting Form: Fillable Word | PDF
Licensed or contracted agencies are required to report critical incidents (serious and significant adverse incidents) to the Office of Substance Abuse and Mental Health Services (SAMHS). Instructions for completing and submitting critical incident information are on the form. Examples of incidents that are provided on the form are not all-inclusive. Since programs must exercise judgment in reporting incidents, reporting staff are encouraged to contact SAMHS regarding any questions about whether an event is reportable. Form Directions. If you have any questions, please contact Wanita.Page@Maine.gov or call 287-7217.
The Office has developed an Electronic Waiting List (EWL) as part of SAMHSA’s Substance Abuse Prevention and Treatment Block Grant (SAPTBG) requirement that waiting list information be collected in a timely manner. The manuals for Treatment Providers and Opioid Treatment Providers give instructions on access to the EWL and how to complete EWL data entry. Please contact the TDS program at 287-6337 if you have any questions.PLEASE NOTE: WAITING LISTS SENT IN USING THE OLD FORMAT WILL NO LONGER BE ACCEPTED AND YOUR AGENCY WILL BE CONTACTED AND INSTRUCTED TO REPORT YOUR WAITING LIST ELECTRONICALLY
Outpatient Service Delivery Forms are used by agencies contracted by the Office of Substance Abuse and Mental Health Services to report ambulatory units of service. The forms are completed monthly and sent to SAMHS by the 15th of the month following the month the services were delivered in. Example: April units of service are sent to the SAMHS by May 15th.
Forms may be printed and copied as needed. If you have any questions on how to properly complete this form, or need forms sent to you, please contact the TDS Helpdesk at 287-6337 or by email at: TDS.Helpdesk@maine.gov.