Form CCL.028 "Notification of Injury, Illness or Critical Incident" - Kansas

What Is Form CCL.028?

This is a legal form that was released by the Kansas Department of Health & Environment - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Kansas Department of Health & Environment;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCL.028 by clicking the link below or browse more documents and templates provided by the Kansas Department of Health & Environment.

ADVERTISEMENT
ADVERTISEMENT

Download Form CCL.028 "Notification of Injury, Illness or Critical Incident" - Kansas

1445 times
Rate (4.4 / 5) 101 votes
Kansas Department of Health and Environment
CCL. 028
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson Street, Suite 200
Topeka, KS 66612-1274
Phone: (785) 296-1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
Notification of Injury, Illness or Critical Incident
This form is to be used to report injury or illness of children or youth in child care or school age programs.
N
License #:
Date Completed (MM/DD/YYYY):
ame of Facility (exactly as it appears on the license):
Street Address of Facility:
City:
County:
SECTION I: TYPE OF NOTIFICATION: =========================================================================================================
Indicate type of report:
_____ Illness
_____
Injury
_____ Critical Incident such as missing child, fire, etc.
SECTION II: WHO WAS INVOLVED: ===========================================================================================================
First and Last Name of Child or Youth:
Date of Birth (MM/DD/YYYY):
========================================================================================================================================
SECTION III: DESCRIPTION OF INJURY, ILLNESS OR CRITICAL INCIDENT:
Date of Incident (MM/DD/YYYY)
Time of Incident (HH:MM)
Description of Injury, Illness or Critical Incident
including what happened, location of children or
youth at the time, etc.
Action taken by the facility. What did you do?
Remarks about the child’s initial appearance
and condition if illness or injury

Was Medical attention required? (Yes or No).
Yes
 On Site
Description:
If Yes, describe and note if on site or
No
 Clinic/Hospital
transported to clinic/hospital.
Kansas Department of Health and Environment
CCL. 028
Rev. 3/2017
Bureau of Family Health
Child Care Licensing Program
1000 SW Jackson Street, Suite 200
Topeka, KS 66612-1274
Phone: (785) 296-1270 Fax: (785) 559-4244
Website: www.kdheks.gov/kidsnet
Notification of Injury, Illness or Critical Incident
This form is to be used to report injury or illness of children or youth in child care or school age programs.
N
License #:
Date Completed (MM/DD/YYYY):
ame of Facility (exactly as it appears on the license):
Street Address of Facility:
City:
County:
SECTION I: TYPE OF NOTIFICATION: =========================================================================================================
Indicate type of report:
_____ Illness
_____
Injury
_____ Critical Incident such as missing child, fire, etc.
SECTION II: WHO WAS INVOLVED: ===========================================================================================================
First and Last Name of Child or Youth:
Date of Birth (MM/DD/YYYY):
========================================================================================================================================
SECTION III: DESCRIPTION OF INJURY, ILLNESS OR CRITICAL INCIDENT:
Date of Incident (MM/DD/YYYY)
Time of Incident (HH:MM)
Description of Injury, Illness or Critical Incident
including what happened, location of children or
youth at the time, etc.
Action taken by the facility. What did you do?
Remarks about the child’s initial appearance
and condition if illness or injury

Was Medical attention required? (Yes or No).
Yes
 On Site
Description:
If Yes, describe and note if on site or
No
 Clinic/Hospital
transported to clinic/hospital.
NOTES
Date
Comments/Remarks
First and Last Name of adult(s) responsible and/or observing the incident:
Relationship to the Facility:
(Staff member, Volunteer, Observer, etc.)
I attest, under penalty of perjury, that to the best of my knowledge, the information provided on this form is true and correct.
Print First and Last Name of Individual Completing this Form:
Signature:
Date Signed (MM/DD/YYYY):
Page of 2