QUALITY IMPROVEMENT – CRITICAL INCIDENT & ABUSE REPORT
PLEASE FORWARD TO:
CalOptima Quality Improvement Department
505 City Parkway West, Orange, CA 92868
Email: qualityofcare@caloptima.org / FAX: 657-900-1615
Check the Appropriate Service
Date of Notification:
(MM/DD/YYYY):
(M/F)
Name:
(where incident occurred)
Name:
Address:
(MM/DD/YYYY)
Name of Staff Reporting Incident:
[Any actual or alleged event or situation that creates a significant risk of substantial or
serious harm to the physical or mental health, safety or well-being of a member.]
Mental anguish caused by willful use of offensive,
abusive or demeaning language by caretaker
Use of bodily or chemical restraints on an individual which is
not in compliance with federal or state laws and administrative
Knowing, reckless or intentional acts of failures to
act which cause injury or death to an individual or which
places that individual at risk of injury or death
Unauthorized use or the use of excessive force in the
placement of bodily restraints on an individual
Corporal punishment or striking of an individual
SUMMARIZE THE INCIDENT
Attach related records and supporting documentation including reports made to others.
CASE REFERRED TO:
