Bcal 4605 Form PDF Details

The BCAL 4605 form, a critical document mandated by the State of Michigan and managed by the Michigan Department of Human Services Bureau of Children and Adult Licensing, plays a vital role in ensuring the safety and welfare of children in care facilities. As a streamlined method for reporting various incidents, including accidents, illnesses, deaths, and fires, this form necessitates prompt and accurate documentation, reflecting the seriousness with which the state regards the well-being of children under professional care. It requires detailed information about the incident, including whether it was immediately reported to BCAL, specifics about the child or children involved, details regarding the caregiver or witnesses, and an exhaustive account of the incident itself. Moreover, it asks for information on first aid administered, medical treatment provided, and any disabilities or health issues pertinent to the child involved in the incident. Additionally, the BCAL 4605 form includes sections for documenting notifications made to law enforcement, fire marshals, parents, or legal guardians, ensuring a comprehensive approach to incident management and response. The form concludes with spaces for signatures from the person completing the report and the facility's registrant, licensee, or responsible person, underscoring the importance of accountability and adherence to legal and ethical standards in the care of children.

QuestionAnswer
Form NameBcal 4605 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesBCAL-4605, Licensee, BCAL, Birthdate

Form Preview Example

INCIDENT REPORT

STATE OF MICHIGAN

Michigan Department of Human Services

Bureau of Children and Adult Licensing

 

 

 

INCIDENT

 

 

ACCIDENT

 

ILLNESS

 

 

DEATH

 

FIRE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was the incident phoned to BCAL?

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

If yes, date and time

 

If no, contact your licensing consultant within 24 hours of the incident.

 

 

 

 

 

 

FACILITY

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration/License Number

 

 

Facility Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility/Home/Provider Name

 

 

 

 

 

 

 

 

Address (Street Number and Name)

County

City

State

Zip Code

CHILD(REN) IN CARE INVOLVED

Name

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birthdate

 

Sex

 

 

 

 

Birthdate

Sex

 

 

 

 

 

 

 

 

 

 

M

 

 

F

 

 

 

M

 

 

 

F

Home Address (Street Number & Name)

 

 

 

 

Home Address (Street Number & Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

 

 

Zip Code

City

 

State

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone Number

 

 

 

 

 

 

 

 

Home Phone Number

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

Name of Parent

 

Alternative Phone Number

Name of Parent

Alternative Phone Number

 

 

 

(

 

 

)

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAREGIVER/OTHER PERSON(S) INVOLVED / WITNESS(ES)

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address (Street Number and Name)

 

 

 

 

 

 

 

 

Address (Street Number and Name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

 

Phone Number

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INCIDENT DETAILS

 

 

Incident

 

A.M.

 

 

Date:

Time:

P.M.

Describe the incident. Be specific.

Location:

BCAL-4605 (7-12) MS Word

1

Was First Aid Given?

If yes, when?

By Whom?

Yes

 

No

 

 

N/A

 

 

 

 

 

 

 

 

 

 

Illness or Injury, if applicable

 

 

 

Where Child Received Medical Treatment, if known

Phone Number of Treating Physician, Medical Facility, Hospital, if applicable

Any Handicaps, Health Problems, or Exceptions Listed on the Child’s Health Records, if applicable

If Fire, Describe Damage

PERSON(S) NOTIFIED (Law enforcement, fire marshal, parent/legal guardian, etc.):

NAME OF PERSON NOTIFIED

NOTIFICATION DATE

NOTIFICATION

TIME

 

 

 

 

A.M.

 

 

 

:

P.M.

 

 

 

 

A.M.

 

 

 

:

P.M.

 

 

 

 

 

 

 

 

A.M.

 

 

 

:

P.M.

 

 

 

 

 

 

 

 

 

Signature of Person Completing This Report

Title

 

Date

 

 

 

 

 

 

Signature of Registrant/Licensee/Responsible Person

Title

 

Date

 

 

 

 

 

 

Department of Human Services (DHS) will not discriminate against any

 

 

individual or group because of race, religion, age, national origin, color, height,

AUTHORITY:

1973 PA 116

weight, marital status, sex, sexual orientation, gender identity or expression,

COMPLETION:

Voluntary/Mandatory

political beliefs or disability. If you need help with reading, writing, hearing,

PENALTY:

May be in violation of licensing rule.

etc., under the Americans with Disabilities Act, you are invited to make your

 

 

needs known to a DHS office in your area.

 

 

BCAL-4605 (7-12) MS Word

2

 

How to Edit Bcal 4605 Form Online for Free

With the online tool for PDF editing by FormsPal, it is easy to fill out or edit DHS right here and now. To retain our tool on the forefront of efficiency, we strive to put into action user-driven capabilities and enhancements regularly. We are routinely looking for suggestions - assist us with revampimg how you work with PDF documents. To begin your journey, consider these easy steps:

Step 1: Open the PDF file inside our tool by clicking the "Get Form Button" in the top section of this page.

Step 2: With our handy PDF editing tool, it is easy to do more than just fill in blanks. Express yourself and make your docs seem professional with custom textual content added in, or optimize the file's original content to perfection - all backed up by an ability to add any images and sign it off.

If you want to fill out this document, make sure that you enter the right information in each blank field:

1. You have to complete the DHS properly, therefore be mindful while filling in the sections containing these specific blanks:

Step # 1 for completing Birthdate

2. Just after filling in the previous part, go on to the next stage and enter the necessary particulars in these fields - Home Address Street Number Name, Home Address Street Number Name, City, Home Phone Number, Name of Parent, State, Zip Code, City, State, Zip Code, Alternative Phone Number, Home Phone Number, Name of Parent, Alternative Phone Number, and CAREGIVEROTHER PERSONS INVOLVED .

Birthdate completion process shown (stage 2)

3. Completing BCAL MS Word is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Birthdate writing process detailed (stage 3)

4. The next section will require your involvement in the following parts: Was First Aid Given Yes No Illness, If yes when, Where Child Received Medical, By Whom, Phone Number of Treating Physician, Any Handicaps Health Problems or, If Fire Describe Damage, PERSONS NOTIFIED Law enforcement, Name of Person Notified, Notification Date, Notification, Time, AM PM, and AM PM. Make sure you type in all needed info to move forward.

By Whom, If yes when, and PERSONS NOTIFIED Law enforcement inside Birthdate

5. This form needs to be completed by filling out this section. Further you will see an extensive listing of blanks that require appropriate details for your document submission to be accomplished: Signature of Person Completing, Signature of, Title, Title, AM PM, Date, and Date.

Stage # 5 of completing Birthdate

Be very mindful while completing Signature of Person Completing and Signature of, since this is where a lot of people make some mistakes.

Step 3: Once you've looked once again at the details in the fields, press "Done" to finalize your form at FormsPal. Right after registering a7-day free trial account here, you'll be able to download DHS or email it right away. The form will also be accessible from your personal account page with your changes. FormsPal guarantees your information privacy via a protected method that in no way records or distributes any kind of personal data provided. Be assured knowing your files are kept protected every time you use our editor!

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