Missouri Department Of Social Services Children's Division Residential Program Unit Critical Incident Report	P. O. Box 88 Jefferson City, MO 65103
Name of Agency / Operating Site
Name Of Child(ren) Involved:
Name Of Staff Involved:
Staff Present:
Other Child(ren) Present:
Date of Incident:	Time Began:	Time Ended:	Place:
Type Of Incident:	Type Of Action Taken: (Include Date And Time)
Injury/Illness	First Aid Given:
Child Death	Doctor or Nurse Consulted:
Alleged Abuse	Taken to Hospital:
Physical Aggression	Unsafe Property Removed:
Sexual Aggression/Sexual abuse	Hotline Called:
Fire-setting	Loss of Level(s):
Restraint	Consequences Given:
Criminal Conduct	On Call Staff Notified:
Suicide Attempt/Self Harming	Police Called:
Medication Error	CD Staff Called:
Elopement	Parent/Guardian Called:
Property Damage	Licensing Unit Notified:
Report of Abuse or Neglect	Other (Describe):
Other (Explain)
Describe what took place before the incident.
Describe any actions staff took to prevent the incident.
Describe in detail the events of the incident: (Give Details Of Who, What, When, Where, Why And How. Just state facts. DO NOT INCLUDE OPINION. Use another sheet if necessary).
Describe any discipline or procedure following the incident as well as corrective action taken by the agency.
Reported To	Date	Time	By Whom
Licensing
CD Case Manager
Police/Sheriff
Parent
Other
Signature	Date
Reviewer	Date