Appendix E Critical Incident Form

Appendix E

Critical Incident Form

If a study respondent has become distressed, expressed that he/she is considering suicide, expressed that he/she is considering harming another person, or discloses that he/she has been the victim of child abuse or neglect, this form must be filled out and the instructions on this form must be implemented.

1. Which of the following have been expressed/revealed by the respondent during this interview? (CIRCLE ALL THAT APPLY)

EMOTIONAL DISTRESS 1

SUICIDAL IDEAS OR INTENT 2

HOMICIDAL IDEAS OR INTENT 3

VICTIM OF ABUSE AND/OR NEGLECT 4

2. What, specifically, did you learn/observe?

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

3. At the end of your interview session, accompany the respondent to meet with [DESIGNATED SITE STAFF] before you leave the health center. She/he will refer the respondent to a psychologist or psychiatrist, as appropriate, and/or initiate a report to Child Protective Services, as warranted.

4. DATE REFERRED : ___________________

INTERVIEWER’S SIGNATURE: ______________________________

[SITE STAFF MEMBER’S] SIGNATURE: __________________________________

5. Within 24 hours of having invoked this procedure, contact Tim Flanigan [(919) 541-6000 ext. 7743] and the RTI Project Director, Kathleen Considine [(919) 541-6000 ext. 6612].

CASE ID # ____ ____ ____ ____