Report A Critical Incident

The Office of Licensing (OL) Code of Conduct and Client Rights (R501-1-11-1(p)(i)), requires any licensee or staff member who is aware of, or suspects abuse, neglect, harm, mistreatment, fraud or exploitation to ensure that a report is made to OL. We investigate all reports. If a critical incident has occurred at your facility, please report it using the form below.

Please view the DHS Incident Reporting Guide to assist in understanding what constitutes an incident, what needs to be reported, and how it should be reported and documented.

If you are a member of the public with a concern about a licensed or unlicensed facility, please fill out the Submit A Concern form instead of the one below.

**For critical incidents related to COVID-19, please click here**

NOTE The link to this page has been updated. If the form is not working, please click here and update your shortcut.

Note: All fields are required to be filled out.

Your name:

Your email:

Your phone number:

Program or provider name:

Site name/location (if applicable):

License type and/or license number:

Are you a DHS-contracted provider?
YesNo

Incident type (select all that apply):

Unique initials of all involved staff (to match initials identified on staff lists):

Unique initials of all involved clients (to match initials identified on client lists):

Names of all involved witnesses:

Date, time and location of incident (and discovery of incident, if different):

Summary of the incident:

Actions taken:

Actions you plan to take:

Enter the email address(es) of the DHS Division Caseworker(s) who is/are required to receive notification regarding this incident in addition to this OL notice:

Attach file (optional - one file only):

Report A Critical Incident

**NOTE** The link to this page has been updated. If the form is not working, please click here and update your shortcut.

NOTE The link to this page has been updated. If the form is not working, please click here and update your shortcut.