Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to access the form and ensure it opens in a suitable editor for your needs.
2. Begin by entering the date of the report in the designated field. This should reflect the current date when you are completing the report.
3. Fill in the member's name in the format of Last, First, Middle Initial. Ensure that the spelling is accurate.
4. Indicate the level of care in which the member is involved and the member's home address, including the county.
5. Enter the provider contact name and their telephone number for follow-up communications.
6. Record the member's date of birth and the date of the incident being reported.
7. Specify the location where the incident took place.
8. Note the date when the provider was notified of the incident.
9. Identify all provider staff involved in the incident.
10. Indicate if this report is an addendum to a previously submitted report by selecting ‘Yes’ or ‘No’. If yes, provide the date of the initial report.
11. Fill in the date of admission to the facility.
12. Record the time of the incident.
13. Select the type of incident from the provided options, ensuring you follow the relevant PerformCare Policy.
14. Document the outcome or resolution of the event, including any medical or crisis assessments that took place.
15. Describe what actions have been taken to prevent reoccurrence of the incident.
16. Complete the mandatory notification section, indicating to which agencies notifications were made, along with applicable details like the date and reference number.
17. Finally, provide your name, title, contact number, and signature along with the date of submission.
18. Once all fields are filled out accurately, save your changes, and then download, print, or share the form as necessary.

Complete your PA PerformCare Critical Incident Report online to ensure timely and accurate reporting.