NON-CRITICAL INCIDENT REPORT (NON-CIR)

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*

Select

Date of Non-Critical Incident*

Date Program Aware of Incident*

Staff Involved?*

Please select one:

Yes

Type of Non-Critical Incident (SMH)*

Reminder: Privacy Incidents and suspected FWA are considered non-critical incidents that need to be reported using the established processes for each and do not need to be reported using this form. For PIR, contact Business Assurance & Compliance (BAC). For suspected FWA, contact your COR and QA directly. If there is a Privacy Incident or suspected FWA connected to the incident being reported, please include confirmation that reporting for either took place in the incident summary below.

Please select one:

Type of Non-Critical Incident (DMC)*

Please select one:

Type of Non-Critical Incident (Non-treatment)*

Please select one:

Report of findings indicated*

Yes

Please explain:*

Location of Incident*

Please select one:

Select

Please explain:*

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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