Lic 624 - Unusual Incident/injury Report
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2STATE 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)
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