CIR Critical Incident Reporting Form Name Client Name Date of the Incident Incident Location Time of the Incident Severe Medical Event: Threat of Suicide Attempted Suicide Death Unplanned Hospital Admission: Psychiatric Facility Result of a Medication Error Transport by Ambulance Medication Event resulting in the need for emergency medical treatment Law Enforcement Involvement: Criminal Behavioral Loss of Property (more than $500): Fire Natural Disaster Theft Behavioral Destruction Missing Person: Lost In Danger Community Protection Issue Police Notified Unusual or Sigificant incident that may attract media attention Use of highly restrictive procedure: P.R.N. medication for Behavoral Control Physical Hold Authorized in Protective Intervention Plan (PIP) Injury Incident Details Send
