Report an Incident or Injury

Complete this form to report an incident or injury to PICS Human Resources. Please allow 48 hours for processing. You also have the option to report to PICS Human Resources by phone at 651-967-5060 ext. 2315.

Please note - All incidents or injuries must be reported within 24 hours of when the program became aware of the situation. A separate report must be completed for each person - do not use identifying information (ex: names or initials if the incident or injury involved another person receiving services. PICS Human Resources will contact you for further information.



Your First & Last Name


Phone Number
() -  - 

Email (optional)


Mailing Address (optional)


Date of Incident or Injury
 [None]  

Location of Incident or Injury


People Involved with Incident or Injury (Select All That Apply):

Type of Incident or Injury (Select All That Apply):