Critical Incident Reporting Form

Stage 1: Reporter

Date

Person Completing Form

Client Name

Select whether this is a Hotline Report (Section A) or Other Critical Incident (Section B). Complete Follow-up actions below.

Section A — Hotline Reporting

Section B — Other Critical Incidents

Date of Incident

Time

Location

Incident Description

Persons Present

Follow Up

Actions Taken

Reporter Sign-off & Routing

Reporter Name

Reporter Email Address

Supervisor Email Address (Sends notification to Stage 2)

Reporter Touchscreen Signature