Mental Health Waiver Critical Incident Submission Form
Person Reporting
Contact Name
Date of Incident
Phone Number (
_/_ _/_
MH Waiver Agency Name _
)
Time of Incident
_-_
:_
__AM/PM_
_
Incident Details
Location of Incident
Client’s Residence
Nursing Home
Community
Other Location (please specify)
Agency Office/Facility
Incident Category
Client Abuse Alleged
Physical Abuse Alleged
Insufficient information at this time
Emergency Evacuation
Verbal Abuse Alleged
Fire
Violation of client’s rights
Bomb
Breach of client’s confidential information
Other
Death
Federal Notification
Suicide
Secret Service
Homicide
FBI
Accident
Other
Accidental Overdose (resulting in death)
Medical Event
Medical Error
Accidental Injury
Illness, Age or Medical Reason
Accidental Overdose (did not result in death)
Please fax completed form to 860-638-5302, Attn: Dan Gerwien
Updated 2/3/14
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Mental Health Waiver Critical Incident Submission Form
Medication Error/Reaction
Firearms
Medical Event- Other
Hostage
Drug Sale/Distribution/Possession
Missing Client
Missing, Risk to self or others
Missing, no known risk
Homicide/Manslaughter
Serious Suicide Attempt
Suicide Attempt by Active Participant
Property Damage
Property Damage
Suicide Attempt within 30 days of Discharge
from Mental Health Waiver
Serious Crime Alleged
Threats
Physical Assault
Threats to Agency
Sexual Assault
Threats to Person
Risk of Injury to Minor
Other
Arson
Other incident (please specify)
Please check any substances that were present at the incident
Alcohol
Over-the-counter Medication
Prescribed Medication
No Evidence of substances being present
Illicit Drug(s)
If present, is there evidence that
the incident may have been the
result of substance overdose
(alcohol, drug, etc.)?
Yes
No
Please fax completed form to 860-638-5302, Attn: Dan Gerwien
Updated 2/3/14
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Mental Health Waiver Critical Incident Submission Form
Is it likely that this incident will cause media coverage?
Already Reported
Not likely to be reported
Likely or possible that it will be reported
Individuals Involved in Incident
Client Name
Client Medicaid ID or SSN
Client Date of Birth _ _/_
_/_
_
What was the client’s role in the incident?
Victim
Perpetrator
Other (please specify)
Is client involved currently enrolled on the MH Waiver?
Yes, client is currently enrolled
No, client unenrolled within the past 30 days
Please describe the events of the incident, specifying
individuals involved and why incident occurred
Please fax completed form to 860-638-5302, Attn: Dan Gerwien
Updated 2/3/14
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