Form LIC 624 at a glance
What it is: LIC 624 is the Unusual Incident/Injury Report of the California Department of Social Services Community Care Licensing Division.
Where and when to file: Submit the written report within 7 days of occurrence.
A filled-in Form LIC 624 example: a resident leaves without permission
How to fill out Form LIC 624, box by box
Name of facility, address and telephone number
Enter the name of facility, the facility file number, the telephone number, the address and the city, state, zip.
Clients/residents involved
For each of the clients/residents involved, enter the client or resident, date occurred, age, sex and date of admission.
Type of incident
Under TYPE OF INCIDENT, the form prints these boxes: Unauthorized Absence; Aggressive Act/Self; Aggressive Act/Another Client; Aggressive Act/Staff; Aggressive Act/Family, Visitors; Alleged Violation of Rights; Rape; Pregnancy; Suicide Attempt; Other; Injury-Accident; Injury-Unknown Origin; Injury-From another Client; Injury-From behavior episode; Epidemic Outbreak; Hospitalization; Medical Emergency; Other Sexual Incident; Theft; Fire; Property Damage and Other (explain). Under Alleged Client Abuse, the form prints these boxes: Sexual, Physical, Psychological, Financial and Neglect.
Describe event or incident
Under DESCRIBE EVENT OR INCIDENT, include date, time, location, perpetrator, nature of incident, any antecedents leading up to incident and how clients were affected, including any injuries.
Person(s) who observed the incident/injury
Enter the person(s) who observed the incident/injury.
Immediate action taken
Explain what immediate action was taken, and include persons contacted.
Medical treatment necessary?
Mark YES or NO for medical treatment necessary; if YES, give the nature of treatment.
Enter where administered and administered by.
Enter follow-up treatment, if any.
Action taken or planned
Enter the action taken or planned, by whom and anticipated results.
Licensee/supervisor comments
Enter the licensee/supervisor comments.
Report submitted by and reviewed/approved by
Under REPORT SUBMITTED BY, enter the name and title and the date.
Under REPORT REVIEWED/APPROVED BY, enter the name and title and the date.
Agencies/individuals notified
Under AGENCIES/INDIVIDUALS NOTIFIED, specify name and telephone number for each: Licensing, Adult/Child Protective Services, Long Term Care Ombudsman, Parent/Guardian/Conservator, Law Enforcement and Placement Agency.
More rules for Form LIC 624
Retain a copy of the report in the client's file.
Common questions about Form LIC 624
Is there a deadline?
Notify the licensing agency, placement agency and responsible persons, if any, by next working day. Submit the written report within 7 days of occurrence.
Sources
[1] Form LIC 624 (4/99), Unusual Incident/Injury Report, California Department of Social Services (the Official source link on this page).
