NON-CRITICAL INCIDENT REPORT (NON-CIR)

County of San Diego Behavioral Health Services (BHS)

FAX: 619-236-1953 / Email: QIMatters.HHSA.sdcounty.ca.gov

For consultation regarding Non-CIR's, please contact BHS QA with your questions at QI Matters: QiMatters.hhsa@sdcounty.ca.gov. Reporting of Non-Critical incidents will go directly to your COR.

See Non-CIR FAQ/Tip Sheet posted on the Optum site for additional details for completing the Non-CIR Notification Form located in the Incident Reporting tab of the SMH & DMC-ODS Plans Optum Page.

Name of Staff Reporting

Email Address of Reporting Staff

COR Name

COR Email Address

Contract Number (if known or available)

Agency/Legal Entity Name

Program Name

Program Manager Name

Program Manager Email Address

Program Manager Phone Number

Phone

Program Type

Please select one:

Specialty Mental Health Treatment (SMH)

DMC-ODS Treatment (DMC)

Non-treatment

Client Category

Date of Non-Critical Incident

mm/dd/yyyy

Date Program Aware of Incident

mm/dd/yyyy

Staff Involved?

Please select one:

Yes

Location of Incident

Please select one:

Summary of Incident

Reminder to exclude all PHI. If PHI is submitted, a PIR will be required.

Other Support Services

What other support services was client connected with?

Notifications

Indicate notifications to other departments, counties, or related parties. This includes County of Residence for Out of County Clients and SUD Residential licensing for any non-critical incidents that require reporting.

Program Manager/Designee Attestation

Please select one:

I am the Program Manager and am attesting that the information provided is accurate.

I am submitting on behalf of the Program Manager and am attesting that the information provided is accurate and has been reviewed with the Program Manager.

Send me a copy of my responses

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