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______________________________________

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