Critical Incident Report Form

Prior to using this form, confirm with Dr. Craig Pierce (505-604-4589) and/or Raana Azad (505-205-5641) as to whether or not the situation is “critical.”

Once you have received a green light to report a Critical Incident, please check if your client has a Category of Eligibility code: 001, 003, 004, 081, 083, 084, 090, 091, 092, 093, 094, 095,
100w/NFLOC, or 200w/NFLOC.

If your client is designated with any of the above codes, please call Raana Azad (505-205-5641) to assist you—these CIRs need to be submitted via the following website: https://criticalincident.hsd.state.nm.us

DOWNLOAD FORM HERE: CIR Form (Sept 2018)

IMPORTANT NOTE: Some browsers are experiencing trouble previewing the PDF. However, if you download the document and open it locally, there seems to be no problem with the file itself.

If you are using a MAC a browser other than Internet Explorer, you can click here for more instructions: https://helpx.adobe.com/acrobat/kb/pdf-browser-plugin-configuration.html.

The link to the form can be found directly on the NM-HSD site at http://www.hsd.state.nm.us/uploads/FileLinks/f2ebdd5453634b77a94737130407ac03/CIReport_Form.pdf

For any other potential IT needs, you may contact Jennifer Swanberg at (505) 476-9261 or by email at bh.qualityteam@state.nm.us