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: