REVISED 10/14/22
Provider Name:
Address:
Sample #s:
W#s:
ISC:
Programs: _ CILA _ HBS _ CDS _ SDA _ CRW _ CSW
Date of Review:
Reviewer:
Provider/Agency - Using DDD generated reports and agency/provider records and policy and procedures.
| Yes |
No |
N/A |
Item |
Comments or Issues |
Remediation completed or required by: |
| - |
- |
- |
1. Have all critical incidents (alleged, suspected, or actual occurrence of an incident when there is reason to believe the health and safety of an individual may be adversely affected or and individual may be place at a reasonable risk of harm) been reported through CIRAS? (Exclude abuse, neglect and exploitation.)
- 911 call?
- Death?
- Known injury?
- Law enforcement?
- Medical Emergency?
- Missing individual?
- Peer-to-peer acts?
- Peer-to-staff acts?
- Unauthorized restraint?
- Unknown injury?
- Unscheduled hospitalization?
|
|
|
| - |
W# |
CIRAS Report # |
Type of critical incident: 911 call, Death, Known injury, Law enforcement, Medical emergency, Missing individual, Peer to peer act, Peer to staff act, Unauthorized restraint, Unknown injury, Unscheduled hospitalization |
Date of Incident |
Date provider reported incident |
Did the provider report the incident within two (2) working days of discovering or being informed of the incident? |
Notes/Comments |
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__ Yes __ No |
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__ Yes __ No |
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| 3. |
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__ Yes __ No |
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| 4. |
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__ Yes __ No |
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| 5. |
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__ Yes __ No |
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| 6, |
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__ Yes __ No |
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| 7. |
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__ Yes __ No |
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| 8. |
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__ Yes __ No |
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| 9. |
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__ Yes __ No |
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| 10. |
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__ Yes __ No |
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| 11. |
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__ Yes __ No |
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| 12. |
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__ Yes __ No |
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