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New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

5-21-2012

Subchapter:

1

Forms

Issuance:

21.10

CP&P Form 21-10, Critical Incident Report

 

 

Click here to view, print, or complete CP&P Form 21-10, Critical Incident Report.

 

WHEN TO USE IT 

 

Use this form to report a critical incident involving children or a non child-related incident. See policy at CP&P-IX-D-1-100, Critical Incident Reporting.

 

Do not use this form to report a child fatality or near fatality; instead use the Child Fatality/Near Fatality Report, CP&P Form 21-11. See policy at CP&P-VIII-A-1-100, Child Fatality and Near Fatality Reporting.

 

HOW TO USE IT

 

The CP&P Form 21-10 is a template, prepared by using the on-line form in the computerized Forms Manual. The person investigating the incident completes the form.

 

The CP&P Local Office Worker or IAIU Regional Office staff complete the Critical Incident Report within no more than five (5) working days of the incident, in follow up to the initial oral report. The Local Office Manager or IAIU Regional Supervisor approves the report and submits it to his or her Area Director, who, upon receipt, forwards it to the Office of the CP&P Director or IAIU Central Office.

 

Reports of critical incidents received during non-business hours are handled by the State Central Registry (SCR) in consultation with the on-call SPRU Supervisor or Local Office Manager.  

 

For a child-related critical incident, SCR makes an immediate oral report to the SPRU Worker and the SPRU Supervisor or IAIU After-Hours Supervisor. The on-call SPRU Worker consults the SPRU/IAIU After-Hours Supervisor regarding case handling/response. SPRU staff complete a summary report on the incident and the SPRU/IAIU Supervisor notifies the Local Office Manager or IAIU Regional Supervisor. The Local Office or IAIU Regional Office is required to then complete the CP&P Form 21-10 on the incident.

 

The CP&P Director's Office or IAIU Central Office is responsible for distributing required copies of the CP&P Form 21-10 to other relevant staff, including, but not limited to, the CP&P Director, other Executive Staff, the Office of Legal Affairs and Licensing, Office of Communications and Public Affairs, Office of Labor Relations, and other appropriate staff and/or units. See "Distribution."

 

Note:  The CP&P LO Manager or IAIU Regional Supervisor provides an update to the Area Director within 14 days of the initial report.

 

TIPS FOR COMPLETING THE FORM

 

Complete check boxes and text boxes for required fields. The text boxes for the fields requiring a narrative will expand as they are completed.

 

Complete the text boxes in detail, as follows:

·        Nature of the Incident, Circumstances, and Cause(s)

 

·        Enter a summary of the incident, including pertinent background information; where the incident occurred; details about, and cause of, any injuries/conditions; property damage; reasons for media interest and name of news reporter, newspaper, TV station, Internet sites, if known. Attach any relevant reports, if available, such as newspaper articles, and police, accident, insurance, or medical reports.

 

·        Critical Incident Oral Report Record

 

·        Complete the table tracking all participants making and receiving oral reports from the initial date of the incident to the final office/person reporting. For the person reporting and receiving the call, provide identifying information including name, title/position, and contact information including agency/program.

 

·        Notifications

 

·        Complete text boxes requesting information on notifications to the local police, County Prosecutor's Office, or Human Services Police.

 

·        Current/Previous CP&P Involvement (Describe Case History in Detail)

 

·        Give a description of CP&P involvement, current or previous. Indicate if a sibling's case plan is impacted by the incident.

 

·        Status of Investigation/Immediate Actions Needed

 

·        Enter a concise description of all actions taken to date as a result of the incident. Indicate further action to be taken or recommended; additional information/reports to be forwarded; and anticipated changes in the case plan.

 

If uncertain whether to report specific circumstances, the CP&P Worker or IAIU staff consults his or her immediate Supervisor, who may consult the LO Manager or IAIU Regional Supervisor. If further clarification is needed, consult the Area Director.

 

Note:  The child's name and case ID number for a child-related incident, or the name of the person or subject of the report in a non child-related incident, will prefill in the header, on the top left of the form, when this information is entered in the identifying information fields under the main "Type of Incident" heading. The prefilled information will appear when "Print Preview" is selected and when the form is printed.

 

DISTRIBUTION

 

Original

-

CP&P Local Office or IAIU Regional Office submits to Area Office, which forwards the form to the CP&P Director's Office or IAIU Central Office. CP&P Local Office or IAIU Regional Office submits to Area Office, which forwards the form to the CP&P Director's Office or IAIU Central Office.

 

The signed and approved CP&P Form 21-10 is distributed as indicated below by the CP&P Director's Office or IAIU Central Office:

 

Original

-

CP&P Director

 

Copy

-

Deputy Director, Assistant Director, and/or other DCF or CP&P Administrator

 

Copy

-

Director of IAIU, IAIU Regional Administrator, and/or other IAIU Administrator

 

Copy

-

Office of Legal Affairs and Licensing, Office of Communications and Public Affairs, Office of Labor Relations, Interstate Services Unit, and other offices within DCF, as applicable

 

Copy

-

Local Office Manager/Local Office Administrative File

 

Copy

-

Case Record (as applicable)