Attachment 13 2019 Critical Incident Form

Critical Incident Form

Health Center Patient Survey Participant

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. ON-SITE INTERVIEW  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.

OFF-SITE INTERVIEW  Follow procedures in off-site critical incident protocol and instructions on this form.

4. DATE REFERRED : ___________________

INTERVIEWER’S SIGNATURE: ______________________________

ON-SITE ONLY:

[SITE STAFF MEMBER’S] SIGNATURE: __________________________________

5. Within 24 hours of having invoked this procedure, contact your Field Supervisor and your Regional Supervisor (Name of Regional Supervisor) at _____________ or (Name of Regional Supervisor) at _________________.

CASE ID # __________________

* If an emotionally distressed respondent indicates he/she does not want to meet with or talk to a site staff member please respect his/her wishes unless his/her emotional distress is caused by suicidal ideas/intent, homicidal ideas/intent, or abuse/neglect.

OMB# 0915-0368 Exp. XX/XX/XXXX