FAX: 207-287-9152
Maine Department of Health and Human Services
Office of Substance Abuse and Mental Health Services

VOICE: 207-287-6333	CRITICAL INCIDENT REPORT FORM
EMAIL:  criticalincidents.dhhs@maine.gov

All licensed mental health and/or substance abuse providers, facilities, agencies and programs are required to report Critical Incidents to the Office of Substance Abuse and Mental Health Services (SAMHS) promptly. Reporting, evaluation and analysis of critical incidents are quality improvement activities permitted by Maine statute and mandated by Maine licensing requirements. It is the responsibility of the provider to inform the client or the client’s legal representative about this activity, and obtain written authorization where required, before disclosing confidential or protected health information for reporting purposes. 

Please answer all questions completely and thoroughly, attaching additional sheets as necessary.
The examples of incidents provided are not all inclusive. Providers are expected to exercise good judgment in reporting all serious and significant incidents.

Agency Name:	            Contact Person: 	

Street Address:	                      STATE/COUNTY:                                                        Zip Code:                

Telephone Number:	                                                         Fax Number:

______________________________________________________________________________________________________________

Facility Name:	                    Contact Person:

Street Address                                                   :              STATE/COUNTY:	                                     Zip Code:	

Telephone Number:	                                                          Fax Number:

Check the correct box to categorize the incident:
Level I - Critical Incidents are results in death or serious injury. They significantly jeopardize clients, public safety or program integrity.

Incidents involving clients  must be reported to SAMHS, whether or not the incident took place on the program site. They must be reported by phone to SAMHS within 4 hours after the incident becomes known to staff and must be followed by a typed C.I.R. within 24 hours. *Please do not report incidents that are not client related.*

-Suicide or Homicide

-Other Unexplained or Unattended Death- (Client deaths need to be reported when cause of death is UNKNOWN and when they die alone. If the client is under hospice or other medical care & we are aware of their situation, we do not need a C.I.R.)

-Major medication error, diversion, theft or lost --Injury to client or staff
-Clinical event or major medication error resulting in medical attention or Emergency Care for a client

	-Serious crime perpetrated by client (arson, sexual/assault, hostage) events which present extreme risk of harm to client, staff or public ----Events which may be reported to media
-Other serious Events (Fire, Flood, MVA, Natural Disasters)

Level II - Critical Incidents include significant errors or undesirable events that compromise quality of care or client safety These must be reported within 3 business days on this C.I.R. form, typed.

-Alleged Physical / sexual abuse of client --Suicide Attempt
-Lost or Missing Client

-Major Physical plant disaster

-Diversion of Medication, client refusing when under guarding orders 
-Other Significant event

Client Name
 Client Identification Number:
Parents/Guardian Name (if applicable):

Descriptive Data:	 Male               Female             Age	             Date of Birth:

Current Residence:

Class Member:            Yes            No

                          County:	            Town/City:

Current status of persons involved:  (location I medical status)

Date and time of incident:

Location  of incident:
Incident Description:

Name of Staff involved:  

STAFF RESPONSES
1.   Actions taken to ensure clients safety?

2.	What medical attention was required by any person involved?

3.	What was the administrative response? 

4	

  Follow up:

Ver. October 22, 2015	Critical Incident Reporting Form	2

Name of Persons Notified:  (list the names of all individuals who were notified of the event)

Guardian:

Clients Family: 

Psychiatrist: 

Police: 

Therapist:

Agency Administrator:

Medical Provider:

DHHS Protective Services:

Case Manager/Community Integration Worker:

Program Area Affiliation:  

                                               Mental Health Services                          Substance Abuse Services	

Program Type:  

      Residential        Outpatient         Case Management        Extended Care      Crisis     MAT          	Shelter          Club House         DLS        CRS

Printed Name of Staff Person Completing Report:

Signature of Staff Person Completing Report:		
Date:

Phone Number:                                                                           Fax number:

Supervisor Signature

Ver. October 22, 2015	Critical Incident Reporting Form	3