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Department of Health and Hospitals Office of Aging (State of Louisiana - Office of Technology Services)

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BROWSE STATE OF LOUISIANA - OFFICE OF TECHNOLOGY SERVICES (LA) FORMS

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Department of Health and Hospitals
Office of Aging and Adult Services (OAAS)
Home and Community Based Services (HCBS) Critical Incident Report Form
PARTICIPANT IDENTIFYING INFORMATION:
Name First:
Name Middle (if known):
Name Last:
Address:
City:
State:
Telephone #:
Region:
DOB:
Parish:
Gender:
Male Female
Name of Family/Legal Guardian:
Family/Legal Guardian Address:
Service Type:
CCW
ADHC
Marital Status
Single
Married
Divorced
Separated
Widowed
Race:
African American
White
Hispanic
Asian/Pacific Islande
American Indian
Alaskan
Unknown/Other
Living Situation:
With Relatives
With Other/Unknow
Alone
With Roommate
With Spouse
With Shared Suppor
In Licensed Facility
In Unlicensed Facilit
Homeless
Legal Status:
Competent Major
Interdicted
Emancipated
Minor
Continued Tutorship
Disability: Person having
Institutional Transition:
Yes No
Type:
Nursing Facility
SSC (DC)
ICF/DD (Private)
Autism
Brain/Head Injury
Cerebral Palsy
Dementia
Disease-Related
Epilepsy
Hearing Impairment
Mental Illness
MR Mild
MR Moderate
MR Profound
MR Severe
Paraplegia
Stroke
Speech Dysfunction
Quadriplegia
Substance Abuse
Visual Impairment
None Determinable
Other Physical Disability
Other Developmental Disabil
Reissued September 2, 2014 Page 1 of 5
Replaces 10/4/10 Issuance OAAS-PF-10-014
Department of Health and Hospitals
Office of Aging and Adult Services (OAAS)
Home and Community Based Services (HCBS) Critical Incident Report Form
Participant Name:
SSN:
INCIDENT CATEGORIES: Check only those that apply
Note: All protective services allegations must be verbally reported
Note to Support Coordinator (SC): If the SC discovers/witnesses an Abuse, Neglect, Exploitation or
Extortion incident involving a participant between the ages of 18 -59, the SC should immediately verbally
report the incident to APS. The SC should complete the CIR and keep a copy for his/her record.
Important: The SC shall not enter the information regarding APS Cases aged 18-59 into the Online
Tracking Incident System. This only applies to APS cases aged 18-59, not APS cases aged 60 and above.
APS Incident Type (Participants 18 years and older)
Abuse
Neglect
Exploitation
Extortion
Self Neglect
Major Injury
Fall
Death
Loss or Destruction of Home
Major Medical
Event
Major Behavioral
Incident:
• Attempted Suicide
• Suicidal Threats
• Self- Endangerment
• Elopement/Missing
• Self-Injury
• Offensive Sexual
Behavior
• Sexual Aggression
• Physical Aggression
Major Medication
Incident
• Pharmacy Error
• Staff Error
• Family Error
• Participant Error
Involvement with Law
Enforcement:
Participant arrested
Participant is a victim
of a crime
Reissued September 2, 2014 Page 2 of 5
Replaces 10/4/10 Issuance OAAS-PF-10-014
Department of Health and Hospitals
Office of Aging and Adult Services (OAAS)
Home and Community Based Services (HCBS) Critical Incident Report Form
Participant Name:
SSN:
EVENT INFORMATION
Incident Occurred Date:______/Time:_______ AM or PM
Incident discovered Date:______/Time:________ AM or PM
Location of incident:
Home
Community
Facility
Vehicle
Day Program
DSP notified APS Date:________________/Time:______________ AM or PM
DSP notified Law Enforcement Date:________________/Time:______________ AM or PM
Type of Health Care Admissions and Date of Admissions (check all that apply):
Psychiatric Hospital
Rehabilitation Facility
Emergency Room
Nursing Home
Date:___________
Date:___________
Date:___________
Date:___________
Acute Care Hospital
Respite Center
SS (Developmental Center)
Hospice
Date:___________
Date:___________
Date:___________
Date:___________
Reporter Name:
Relationship:
APS
Child
Child Protection
Curator
Day Program
Direct Service Worker
DSS
Friend/Neighbor
Guardian
Home Health
Hospital
HSS
Law Enforcement
OAAS
OBH
OPH
Other
Parent
Physician
Provider
Supervisor
Self
Sibling
Spouse
Support Coordinato
Under Curator
Support Coordination Agency:
Agency Telephone #:
Support Coordinator (SC) Name
SC Telephone #:
Direct Service Provider:
DSP Telephone #:
Reissued September 2, 2014 Page 3 of 5
Replaces 10/4/10 Issuance OAAS-PF-10-014
Department of Health and Hospitals
Office of Aging and Adult Services (OAAS)
Home and Community Based Services (HCBS) Critical Incident Report Form
HCBS Critical Incident Report Form
Participant Name:
SSN:
Critical Incident Description:
Enter all information rega
rding the incident (i.e., Who, What, When, Where, How, et cetera). Include all specifics and
details related to the incident. Include the name of the individual with the participant at the time of the incident
(including relationship, address, telephone # and name of agency et cetera). Use as many pages as necessary,
numbering, dating and signing each page. (If Law Enforcement was notified, include the name of
the agency, contact person, and address.)
Name of Direct Service Provider:
Date reported to SC:
Time:
Report completed by:
Telephone #:
Date:
Region
Reissued September 2, 2014 Page 4 of 5
Replaces 10/4/10 Issuance OAAS-PF-10-014
Department of Health and Hospitals
Office of Aging and Adult Services (OAAS)
Home and Community Based Services (HCBS) Critical Incident Report Form
Critical Incident Report Description – DSP Follow-Up
Use as many copies of this form as needed to complete your report. Each additional page must be signed and dated
Participant Name:
SSN:
If participant was released from a facility or outpatient procedure, indicate date and time of release:
Date:______/Time:_______ AM or PM
FOR SC USE ONLY: Meets criteria for Major Medical Event: Yes or No
Direct Service Provider Follow-up
Enter any follow-up related to the critical incident: results of medical/dental appointments, labs, discharge
instructions from hospital, change in staffing, medications, treatments, modifications to behavior support
plan, tea
meetings, revision to ISP, etc.
Name of Direct Service Provider:
Date reported to SC:
Time:
Follow-up completed by:
Telephone #:
Date:
Region
Reissued September 2, 2014 Page 5 of 5
Replaces 10/4/10 Issuance OAAS-PF-10-014
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Department of Health and Hospitals Office of Aging (State of Louisiana - Office of Technology Services)

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Completed 15 August 2021

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