Licensing-Critical & Other Incident Reporting Form

Instructions:
1) Fill out all sections of Incident Form
2) Return to top of page and press "File" and "Print" to print a copy of the Incident Report for your records.
3) Return to Incident Report and press "Submit" to send electronically to DCFS.

Facility Name

License Number

Type of Incident

Date of Incident

Time of Incident

Resident(s) Involved in Incident

Staff Involved in Incident or Present at the Time of Incident

Description of Incident

Action Taken as Result of Incident

Person(s) who witnessed incident

Incident Also Reported To

List name(s) of individuals reported to if "other" is selected above.

Name of Staff Reporting Incident

Name of Staff Completing Report

Date of Completion

Print this form before hitting "Submit". Return to top right of page and press "Print" in order to print a copy of the Incident Report for your records.