Living Room Critical Incident Report
Confidentiality Notice: This document contains confidential and privileged information.
Any unauthorized review; use, disclosure or distribution is strictly prohibited.

If there is an emergency or evidence of abuse or neglect, call the on-call RISE supervisor in addition to filling out this form. Your direct supervisor may not see the message in time to respond to the incident.
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Date of incident: *
MM
/
DD
/
YYYY
Time of incident: *
Time
:
Location of incident: *
Name of person completing report: *
Position/Title of person completing the report
Phone number of person completing report: *
Narrative description of the incident: *
Persons affected: (check all that apply) *
Required
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