Form LIC 624B Unusual Incident/Injury Report - Family Child Care Home - California

Form LIC624B is a California Department of Social Services form also known as the "Unusual Incident/injury Report - Family Child Care Home". The latest edition of the form was released in August 1, 2008 and is available for digital filing.

Download an up-to-date fillable Form LIC624B in PDF-format down below or look it up on the California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
UNUSUAL INCIDENT/INJURY REPORT - FAMILY CHILD CARE HOME
1.
FACILITY LICENSE NUMBER:
2.
LICENSEE NAME:
3.
FACILITY NAME:
4.
FACILITY ADDRESS:
Birth Date/Age 7. Sex
10.
Date/Time of
5.
Name of Child(ren) Involved
6.
8. Admission Date
9. Primary Language
M / F
Incident/Injury
11. EVENT REPORTED TO THE DEPARTMENT (CHECK ALL THAT APPLY)
a.
Death of any child from any cause.
b.
Any injury to a child that requires treatment by a medical professional.
c.
Any child absence meaning any instance where a child in care is missing.
d.
Any suspected child abuse or neglect of any child in care. (Must also be reported to local law enforcement or
Child Protective Services.)
e.
Fires or explosions in or on the premises of the family child care home.
f.
A communicable disease outbreak when determined by the local health authority.
g.
Poisonings
h.
Other incident that threatens the physical or emotional health and safety of any child.
12. DESCRIBE WHAT HAPPENED:
13. BRIEFLY DESCRIBE THE INJURY, IF ANY:
14. DESCRIBE STEPS TAKEN TO PREVENT THIS INCIDENT OR INJURY IN THE FUTURE:
15. NAME OF PHYSICIAN OR OTHER HEALTH CARE PROVIDER, IF APPLICABLE:
16. PHYSICIAN OR HEALTH CARE PROVIDER TELEPHONE NUMBER:
(
)
17. NAME AND TELEPHONE NUMBER OF PARENT(S), OR AUTHORIZED REPRESENTATIVE:
18. DATE THE PARENT/AUTHORIZED REPRESENTATIVE OF THE AFFECTED
CHILD WAS NOTIFIED:
19. Agency(ies) Notified
22. Telephone or Fax
20. Name of Person(s) Contacted
21. Date
State Child Care Licensing
(
)
County Child Care Licensing
(
)
Child Protective Services
(
)
Law Enforcement
(
)
23. LICENSEE SIGNATURE
24. TELEPHONE NUMBER.
25.
DATE:
(
)
(TO BE COMPLETED BY DEPARTMENT)
Date report received in Licensing Office: ____________ Date report reviewed and logged : _____________________
EVALUATION OF REPORT:
Follow up inquiry required
Yes
No
Investigation required
Yes
No
REFERRED TO:
Licensing Program Analyst
Date Reviewed:_________________ Case Management Visit
Yes
No
Licensing Program Manager/Sup Date Reviewed:_________________
Regional/Program Manager
Date Reviewed:_________________ Other _________________________________
DISPOSITION:
PAGE 2 of 2
LIC 624B (8/08)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
UNUSUAL INCIDENT/INJURY REPORT - FAMILY CHILD CARE HOME
1.
FACILITY LICENSE NUMBER:
2.
LICENSEE NAME:
3.
FACILITY NAME:
4.
FACILITY ADDRESS:
Birth Date/Age 7. Sex
10.
Date/Time of
5.
Name of Child(ren) Involved
6.
8. Admission Date
9. Primary Language
M / F
Incident/Injury
11. EVENT REPORTED TO THE DEPARTMENT (CHECK ALL THAT APPLY)
a.
Death of any child from any cause.
b.
Any injury to a child that requires treatment by a medical professional.
c.
Any child absence meaning any instance where a child in care is missing.
d.
Any suspected child abuse or neglect of any child in care. (Must also be reported to local law enforcement or
Child Protective Services.)
e.
Fires or explosions in or on the premises of the family child care home.
f.
A communicable disease outbreak when determined by the local health authority.
g.
Poisonings
h.
Other incident that threatens the physical or emotional health and safety of any child.
12. DESCRIBE WHAT HAPPENED:
13. BRIEFLY DESCRIBE THE INJURY, IF ANY:
14. DESCRIBE STEPS TAKEN TO PREVENT THIS INCIDENT OR INJURY IN THE FUTURE:
15. NAME OF PHYSICIAN OR OTHER HEALTH CARE PROVIDER, IF APPLICABLE:
16. PHYSICIAN OR HEALTH CARE PROVIDER TELEPHONE NUMBER:
(
)
17. NAME AND TELEPHONE NUMBER OF PARENT(S), OR AUTHORIZED REPRESENTATIVE:
18. DATE THE PARENT/AUTHORIZED REPRESENTATIVE OF THE AFFECTED
CHILD WAS NOTIFIED:
19. Agency(ies) Notified
22. Telephone or Fax
20. Name of Person(s) Contacted
21. Date
State Child Care Licensing
(
)
County Child Care Licensing
(
)
Child Protective Services
(
)
Law Enforcement
(
)
23. LICENSEE SIGNATURE
24. TELEPHONE NUMBER.
25.
DATE:
(
)
(TO BE COMPLETED BY DEPARTMENT)
Date report received in Licensing Office: ____________ Date report reviewed and logged : _____________________
EVALUATION OF REPORT:
Follow up inquiry required
Yes
No
Investigation required
Yes
No
REFERRED TO:
Licensing Program Analyst
Date Reviewed:_________________ Case Management Visit
Yes
No
Licensing Program Manager/Sup Date Reviewed:_________________
Regional/Program Manager
Date Reviewed:_________________ Other _________________________________
DISPOSITION:
PAGE 2 of 2
LIC 624B (8/08)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
UNUSUAL INCIDENT/INJURY REPORT - FAMILY CHILD CARE HOME
EVENTS THAT MUST BE REPORTED TO PARENTS/AUTHORIZED REPRESENTATIVES
AND/OR THE DEPARTMENT:
A. No later than the same business day, notify a child’s parent or authorized
representative of the events listed in #11 that affect that child.
B. Within the next business day, notify the Department by telephone or fax of the
events listed in #11.
C. If reported to the Department by telephone, submit written report within
7 calendar days of the event.
D. Keep a copy of the report submitted to the Department in the (affected) child’s
record.
GENERAL INSTRUCTIONS FOR COMPLETION
1. Enter the facility number as shown on the license
2. Enter the licensee’s name as shown on license.
3. Enter the name of the facility as shown on the license.
4. Enter the number and street address, city, and zip code.
5. Enter the first and last name of each child involved in the incident or injury.
6. Enter the child’s age or the month, date, and year of birth.
7. Enter the gender of each child as M for Male or F for Female.
8. Enter the month, date, and year each child was accepted into the family child care home.
9. Enter the language that the child or parent speaks (i.e., English, Spanish, etc. ).
10. Enter the month, date, year and the time of day that the incident or injury happened.
11. Event to be reported:
a. Check if any child has died from any cause.
b. Check if a child was injured, and the injury required treatment by a medical professional.
c. Check if a child in care leaves or wanders (is missing) from the facility without permission or supervision, including
when a child is missing during any outing or special event away from the facility, or a child does not return from
school.
d. Check if it is suspected that a child has been abused or neglected.
e. Check if there is a fire or explosion in or on the premises of the family child care home.
f. Check if there is a communicable disease outbreak when determined by the local health authority.
g. Check if any child is poisoned while in care.
h. Check if there is some other incident that threatens the physical or emotional health and safety of any child.
12. Describe what happened. Be specific. Include name of person(s) involved in or suspected of causing the injury.
13. Include medical findings and treatment.
14. Describe how this incident or injury will be prevented in the future.
15. Enter the first and last name and title of the physician or other health care provider providing care to child, if known.
16. Enter the area code and telephone number of the physician or other health care provider.
17. Enter the name(s) and telephone number of the child’s parent(s), or authorized representative(s).
18. Enter the month, date, and year that the child’s parent(s), or authorized representative(s) were notified.
19. Check one or more of the agencies notified of the incident or injury.
20. Enter the name of the person (for each agency) with whom you spoke when reporting the event.
21. Enter the month, day, and year next to the agency person’s name that was contacted.
22. Enter the area code and telephone or fax number of the agency contacted.
23. Enter your signature here.
24. Enter your area code and telephone number.
25. Enter the month, date, and year this report is signed.
PAGE 1 OF 2
LIC 624B (8/08)

Download Form LIC 624B Unusual Incident/Injury Report - Family Child Care Home - California

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