This form is used to report emergency safety interventions and serious incidents occurring in programs certified under Wis. Admin. Code chs.
DHS 40 Mental Health Day Treatment Services for Youth and
DHS 50 Youth Crisis Stabilization Facilities.
Per Wis. Admin. Code §§ DHS 40.08(8)(a) and 50.12(7)(a), programs/facilities shall report all incidences of seclusion, physical restraint, injury, involvement of law enforcement, and elopement (for DHS 50 certified facilities only) to the department within 24 hours of the incident occurring. Reporting shall be completed through the DHS online reporting system. DHS will evaluate the circumstances of each incident, conduct any appropriate follow-up, and identify programs in need of technical assistance, training, policy development, or other quality improvement.
Do not provide any identifying information such as names of individuals and dates of birth in this report unless requested.
Items marked with an asterisk (*) are required.
**Select "Save and Continue Later" at the top of the next page and beyond to save your work and receive instructions on how to come back and complete your report at a later time.**