Incident Report Lic 624 Form – Fill Out and Use This PDF

The Incident Report Lic 624 Form is used to report an incident that could impact the safety or well-being of employees, patients, students and the general public.

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Incident Report Lic 624 Form PDF Details

If you're a business owner, then you know that it's important to keep accurate records of any incidents that occur in your establishment. This is where the Incident Report Lic 624 Form comes in. This form is designed to help you keep track of any and all incidents that take place, from property damage to customer accidents. Having this information on hand can be essential for protecting your business in the event of an insurance claim or legal dispute.make sure you are familiar with the contents of this form so that you can complete it accurately and completely.

We have collected some statistical details about the incident report lic 624 form. Before you fill out the form, it is usually worth checking out more details on it.

Question	Answer
Form Name	Incident Report Lic 624 Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	152
Avg. time to fill out	30 min 58 sec
Other names	california incident report, lic 624 unusual incident injury report, incident injury, unusual incident report form licensing

12

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY	CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
	COMMUNITY CARE LICENSING DIVISION

UNUSUAL INCIDENT/INJURY REPORT

INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY.

SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE.

RETAIN COPY OF REPORT IN CLIENT’S FILE.

NAME OF FACILITY

ADDRESS

FACILITY FILE NUMBER

TELEPHONE NUMBER

( )

CITY, STATE, ZIP

CLIENTS/RESIDENTS INVOLVED

DATE OCCURRED

AGE

SEX

DATE OF ADMISSION

TYPE OF INCIDENT
■ Unauthorized Absence	Alleged Client Abuse	■ Rape	■ Injury-Accident	■ Medical Emergency
■ Aggressive Act/Self	■ Sexual	■ Pregnancy	■ Injury-Unknown Origin	■ Other Sexual Incident
■ Aggressive Act/Another Client	■ Physical	■ Suicide Attempt	■ Injury-From another Client	■ Theft
■ Aggressive Act/Staff	■ Psychological	■ Other	■ Injury-From behavior episode ■ Fire
■ Aggressive Act/Family, Visitors	■ Financial		■ Epidemic Outbreak	■ Property Damage
■ Alleged Violation of Rights	■ Neglect		■ Hospitalization	■ Other (explain)

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:

EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED):

LIC 624 (4/99)

OVER

	MEDICAL TREATMENT NECESSARY? ■ YES ■ NO	IF YES, GIVE NATURE OF TREATMENT:

WHERE ADMINISTERED:

FOLLOW-UP TREATMENT, IF ANY:

ADMINISTERED BY:

ACTION TAKEN OR PLANNED (BY WHOM AND ANTICIPATED RESULTS:

LICENSEE/SUPERVISOR COMMENTS:

NAME OF ATTENDING PHYSICIAN

NAME AND TITLE

REPORT SUBMITTED BY:

NAME AND TITLE

REPORT REVIEWED/APPROVED BY:

DATE

DATE

AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER)

■

■

■

LICENSING______________________________________

LONG TERM CARE OMBUDSMAN___________________

LAW ENFORCEMENT_____________________________

■

■

■

ADULT/CHILD PROTECTIVE SERVICES________________________

PARENT/GUARDIAN/CONSERVATOR__________________________

PLACEMENT AGENCY______________________________________

How to Edit Incident Report Lic 624 Form Online for Free

This PDF editor makes it simple to manage the california incident report file. You should be able to create the file effortlessly through these basic steps.

Step 1: First, select the orange button "Get Form Now".

Step 2: The form editing page is currently available. It's possible to add text or update present details.

The next segments are included in the PDF form you will be completing.

portion of empty spaces in lic 624 unusual incident

Type in the required particulars in PERSONS, WHO, OBSERVED, THE, INCIDENT, INJURY segment.

Filling out lic 624 unusual incident part 2

You could be asked for some valuable details to be able to fill up the LI, C and OVER section.

Filling out lic 624 unusual incident stage 3

Within the field MEDICAL, TREATMENT, NECESSARY YES, NO, IF, YES, GIVE, NATURE, OF, TREATMENT WHERE, ADMINISTERED FOLLOWUP, TREATMENT, IF, ANY ADMINISTERED, BY and LICENSEE, SUPERVISOR, COMMENTS identify the rights and responsibilities of the sides.

stage 4 to completing lic 624 unusual incident

Complete the file by looking at these sections: NAME, OF, ATTENDING, PHYSICIAN REPORT, SUBMITTED, BY REPORT, REVIEWED, APPROVED, BY NAME, AND, TITLE NAME, AND, TITLE DATE, and DATE.

lic 624 unusual incident NAMEOFATTENDINGPHYSICIAN, REPORTSUBMITTEDBY, REPORTREVIEWEDAPPROVEDBY, NAMEANDTITLE, NAMEANDTITLE, DATE, and DATE blanks to complete

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