Serious Incident Report Submittal, Licensed Child Welfare Providers

The purpose of this form is for submission of form DCF-F-cfs2146 Serious Incident Report (SIR) to the Child Welfare Licensing Section. Completion of this form including attaching a completed SIR form and staff statements fulfils reporting requirements for licensed Residential Care Centers for Children and Youth (RCCs), Group Homes (GHs), Shelter Cares (SCs) facilities and private Child Placing Agencies (CPAs).

A separate form must be completed for each incident report.

You should receive an automated email response within 10 minutes of submission of this form. If you do not receive this response please notify licensing staff by emailing

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