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Licensing - Critical Incident Reporting Form

Instructions:
1) Fill out all sections of Critical Incident Form
2) Return to top of page and press "File" and "Print" to print a copy of the Critical Incident Report for your records.
3) Return to Critical Incident Report and press "Submit" to send electronically to DCFS.

Bold indicates required fields

Facility Name
License Number
Type of Incident Injury Sustained While in Seclusion or During Restraint
Unplanned Hospitalization
Suicide Attempt
Elopement
Unexplained Absence
Other
Date of Incident
Time of Incident
Resident(s) Involved in Incident
Separate names with a comma
Staff Involved in Incident or Present at the Time of Incident
Separate names with a comma
Description of Incident
Include scope and severity of incident and likelihood of reoccurance
Action Taken as Result of Incident
Include measures taken to ensure safety and protection
Person(s) who witnessed incident
Separate names with a comma
Incident Also Reported To Child Welfare Placement Worker or Centralized Intake Hotline
Office of Juvenile Justice
Law Enforcement
Parent/Legal Guardian
Other

Select all applicable
Specify Other Agencies Incident Reported To (if selected)
Name of Staff Reporting Incident
Name of Staff Completing Report
Date of Completion
Print this form before hitting "Submit". Return to top of page and press "File" and "Print" to print a copy of the Critical Incident Report for your records.