Long Term Services and Supports Critical Incident Report Today’s Date: REPORT TYPE (Check only one) Death Missing Person Restraint/Seclusion Other: Serious Injury (Requiring Treatment beyond First Aid): Fracture Concussion Laceration Severe Burn Dislocation Other: WHO IS REPORTING Person Making Provider Name Report to LTSS: & Location: Name of Consumer: DETAILS Date of Incident: Where Incident Occurred: Check all that apply: How Provider Became Aware Consumer Family/Guardian Reported Provider/Staff Witnessed of Incident: Other: Check all that apply: Provider Reported Emergency Services (911) Law Enforcement Guardian Incident to: Family/Emergency Contact Other:
Long Term Services and Supports Critical Incident Report Today’s Date: REPORT TYPE (Check only one) Death Missing Person Restraint/Seclusion Other: Serious Injury (Requiring Treatment beyond First Aid): Fracture Concussion Laceration Severe Burn Dislocation Other: WHO IS REPORTING Person Making Report to LTSS: Provider Name & Location: Name of Consumer: DETAILS Date of Incident: Where Incident Occurred: How Provider Became Aware of Incident: Check all that apply: Consumer Family/Guardian Reported Provider/Staff Witnessed Other: Provider Reported Incident to: Check all that apply: Emergency Services (911) Law Enforcement Guardian Family/Emergency Contact Other:
681%20LTSS%20Critical%20Incident%20Report%208.17.docx