Critical Incident Follow-up Report

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NOTE: Please do not include any personal health information (including personal information) in any of the below form fields. Doing so will constitute a privacy breach.

Today's Date (mm/dd/yyyy)

Incident Number

Name of Provider:

Contact Information of Submitting Person

First name

Last name

Phone

For example, 902-555-5555

Action taken to address immediate safety of clients/staff:

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Action taken (to prevent re-occurrence):

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Have any other organizations been contacted regarding this critical incident?

For example, NSH, College of nursing, Technology company, police, etc

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Privacy Statement

The information provided on this form is collected, used, and disclosed in accordance with the Critical Incident Reporting Policy, Personal Health Information Act and the Freedom of Information and Protection of Privacy Act. It will not be collected, used or disclosed, for any other purpose except as authorized by law.