Critical Incident Report This form is to be completed any time there is an incident at Catholic Social Services programs or sites. Program Administration 3rd Ave. Resource & Navigation Center Brother Francis Shelter Clare House Complex Care Family Disability Services Homeless Family Services Refugee Assistance and Immigration Services St. Francis House Food Pantry Type of IncidentMedication errorsUse of physical intervention (restraint)-an action that is specifically prohibited at CSSDeath of a recipient during provision of serviceAccident/ incident requiring medical interventionEvent requiring emergency medical attention during provision of serviceMissing person in the care of CSSHarm to self or othersThreat of harm to self or othersEvents requiring law enforcement responseIncidents when 911 or emergency responders are calledSearchReport to Office of Childrens’ Services (OCS)/Adult Protective Services (APS)— (NOTE: BFS does not need to have a CIR completed.)Anything that otherwise plausibly count as a substantial risk to staff, guests, clients, participants, resources, etc..This incident involves:ClientEmployeeVolunteerGeneral PublicName of person/s this report is concerning (use initials or client number if this is a client): Witnesses: Name of person completing this report: Date and time of incident: Location of the incident: Please describe what happened: What factors contributed to the incident? Has this type of incident happened in the past? Has the program taken action in the past to prevent this type of incident? If so, what? Did the program director/ manager or other supervisor debrief with staff or client, as appropriate? Was this incident reported to other entities? If so, which one/s and when? Δ