Unusual Incident Report Form Licensing 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.

QuestionAnswer
Form NameIncident Report Lic 624 Form
Form Length2 pages
Fillable?Yes
Fillable fields152
Avg. time to fill out30 min 58 sec
Other namescalifornia incident report, incident injury, lic 624 incident report, lic 624 california form

Form Preview Example

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

This PDF editor makes it simple to manage the unusual incident report form california 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 california form

Step 3: Hit the "Done" button. Now you can upload your PDF form to your gadget. Additionally, you can deliver it through email.

Step 4: It may be simpler to have copies of the document. There is no doubt that we are not going to reveal or view your particulars.

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .