Lic 624 - Unusual Incident/injury Report Page 2
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2MEDICAL 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______________________________________
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