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APPENDIX I CRITICAL INCIDENT REPORT FORM & CRITICAL INCIDENT REPORTING PROCEDURES Family Violence Prevention Program Department of Family Services and Housing Critical Incident Report Family Violence

How to fill out critical incident report form

How to Fill Out a Critical Incident Report Form:

1. Begin by providing your personal information. This typically includes your name, job title or affiliation, and contact details. It is important to include accurate and up-to-date information to ensure proper communication regarding the incident.
2. Next, specify the date and time of the incident. This helps establish a timeline and provides crucial information for further investigation or analysis.
3. Describe the location of the incident. Be as specific as possible, including addresses, room numbers, or any other relevant details to help identify the exact place where the incident occurred.
4. Provide a detailed account of the incident. Describe what happened, who was involved, and any additional pertinent information. Be objective and factual, avoiding any personal opinions or assumptions.
5. Include any evidence or supporting documentation. If available, attach photos, videos, or any other relevant materials that can assist in understanding the incident. This could be surveillance footage, witness statements, or related documents.
6. Outline any injuries or damages that occurred as a result of the incident. Include information about individuals affected, the severity of injuries, and any property damage that may have been caused.
7. Indicate if emergency services were contacted or involved. If applicable, provide the details of the emergency services notified, such as police, fire department, or medical personnel.
8. List any witnesses to the incident. Include their contact information, if available, as they may be important for further investigation or as potential sources of additional information.
9. State the actions taken immediately following the incident. Describe any steps you or others took to ensure the safety and well-being of those involved, as well as any measures taken to mitigate further risks or damages.

Who Needs a Critical Incident Report Form?

A critical incident report form may be required by various organizations or individuals who deal with potential risks or emergencies. Here are some examples of who may need a critical incident report form:

1. Employers: Businesses, companies, and organizations often require incident report forms to ensure the health and safety of their employees, clients, or customers. This helps track and address any incidents that may occur within their premises or as part of their operations.
2. Healthcare Providers: Hospitals, clinics, and other healthcare settings typically utilize incident report forms to document and analyze any adverse events or medical errors that may impact patient care. This information is crucial for quality improvement and patient safety initiatives.
3. Educational Institutions: Schools, colleges, and universities may utilize incident report forms to report and address safety concerns, accidents, or disciplinary issues that occur on their premises. This helps maintain a safe and secure learning environment for students, staff, and visitors.
4. Law Enforcement Agencies: Police departments and other law enforcement agencies often require incident report forms to document criminal activities, accidents, or any incidents that may require investigation. This serves as an official record of events and assists in the legal process.
5. Government Agencies: Various government agencies may utilize incident report forms to track and address incidents related to public safety, environmental concerns, or regulatory compliance. This helps ensure accountability and corrective actions are taken when necessary.

Remember, the specific need for a critical incident report form may vary depending on the industry, organization, or individual requirements. It is important to follow any guidelines or procedures provided by the relevant authority when filling out such forms.

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