Form LIC 624 Unusual Incident/Injury Report - California

What Is Form LIC 624?

Form LIC 624, Unusual Incident/Injury Report, also known as the LIC injury report form or the LIC unusual incident report form, is an application created for daycare providers that allows them to report unusual incidents and/or injuries to the appropriate California state agencies.

LIC 624 Form was released by the California Department of Social Services Community Care Licensing Division in April 1999 and can be downloaded from the link below.

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LIC Unusual Incident Report

A licensed child care provider is required to submit current and accurate reports to Community Care Licensing in a timely fashion. Unusual incidents (LIC 624 for child care centers and LIC 624B for family child care homes) is one type of such reports. These reports are mandatory for both family child care homes and centers.

Below are some examples of unusual incidents to be reported:

  • Outbreaks of communicable diseases (e.g. mumps or measles);
  • Suspected child abuse or any incidents that put children in danger, may it be their wandering away from the facility unattended or injuries requiring medical intervention.

The other type of report relates to the facility operation, e.g. personnel changes, contact information changes, and changes to the facility.

Unusual incident reports, thanks to their nature, are filed by phone and in writing. The phone reports are made no later than the next working day after the event occurs. A detailed written report must be filed within 7 days of the event. Personnel changes reports are made within 10 days of the change.

Some events must be reported not only to the Community Care Licensing, but to more than one government agency. Here are some examples:

  • Events involving a public health risk (e.g. outbreak of a communicable disease) are to be reported to the Department of Public Health.
  • Reports of any kind of criminal violation are to be filed to local law enforcement authorities.
  • And suspected child abuse cases must also be reported to a child protective agency.

Form LIC 624 Related Publications

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INSTRUCTIONS :
NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND
UNUSUAL INCIDENT/INJURY
RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY.
REPORT
SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE.
RETAIN COPY OF REPORT IN CLIENT’S FILE.
NAME OF FACILITY
FACILITY FILE NUMBER
TELEPHONE NUMBER
(
)
ADDRESS
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):
OVER
LIC 624 (4/99)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
INSTRUCTIONS :
NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND
UNUSUAL INCIDENT/INJURY
RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY.
REPORT
SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE.
RETAIN COPY OF REPORT IN CLIENT’S FILE.
NAME OF FACILITY
FACILITY FILE NUMBER
TELEPHONE NUMBER
(
)
ADDRESS
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):
OVER
LIC 624 (4/99)
MEDICAL TREATMENT NECESSARY?
YES
NO
IF YES, GIVE NATURE OF TREATMENT:
WHERE ADMINISTERED:
ADMINISTERED BY:
FOLLOW-UP TREATMENT, IF ANY:
ACTION TAKEN OR PLANNED (BY WHOM AND ANTICIPATED RESULTS:
LICENSEE/SUPERVISOR COMMENTS:
NAME OF ATTENDING PHYSICIAN
NAME AND TITLE
DATE
REPORT SUBMITTED BY:
NAME AND TITLE
DATE
REPORT REVIEWED/APPROVED BY:
AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER)
LICENSING______________________________________
ADULT/CHILD PROTECTIVE SERVICES________________________
LONG TERM CARE OMBUDSMAN___________________
PARENT/GUARDIAN/CONSERVATOR__________________________
LAW ENFORCEMENT_____________________________
PLACEMENT AGENCY______________________________________

Download Form LIC 624 Unusual Incident/Injury Report - California

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