Critical Incident Report Form
Please submit this form within two (2 hours of becoming aware of the incident.) to Organization of Hope.  Independent Review Form Critical Incident Reporting Requirements

COMAR 10.63.01.02(B)(19) Definitions:

“Critical incident” means any of the following: (a) Death of a program participant; (b) Life threatening injury to a program participant; (c) Non-consensual sexual activity, as prohibited in COMAR 10.01.18; (d) Any sexual activity between a staff member and a program participant; (e) Unexpected evacuation of a building under circumstances that threaten the life, health or safety of participants; (f) Diversion of medication from the stock of a program providing opioid treatment services; or (g) Any injury related to an opioid medication dispensed by a program providing opioid treatment services.

COMAR 10.63.01.05 (G) Requirements for Licensed Community-Based Behavioral Health Program.

Critical Incident Reports: A licensed program shall report all critical incidents to the Department, or its designee, within five (5) calendar days following the program receiving knowledge of the incident, on the form required by the Department.

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Today's Date *
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Title and Name of the Individual Completing the form *
Credentials of Staff *
Staff Title/Position *
Date of Critical Accident *
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Risk Level of Incident- See Critical Incident Matrix *
Nature of Incident *
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Date Incident Reported to BHA/MCORR/COA *
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