Critical Incident Report

Critical Incident Submission Form

Please complete this form with as much information as possible. We will get back with you via phone or e-mail if clarification is needed.

Your Name:

Title

First Name *

Last Name *

Suffix

Facility

* 'Facility' is required

Your e-mail address:

@ *

Today's Date

/ Month

/ Day

Year

Date of Incident

/ Month

/ Day

Year

Location in Facility:

'Location in Facility:' is required

# of staff involved:

# of inmates involved:

# of staff injured:

Untitled

Escape/Attempt
Assault
Hostage
Riot
Weapon

If a weapon, what type(s)?

'If a weapon, what type(s)?' is required

Description of Incident:

Management's response and any problems with it:

Suggestions for how this could have been prevented: