Unusual Incident/Injury Report F

Unusual Incident/Injury Report Form Procedure

The California Department of Social Services Community Care Licensing Division (CCLD) requires that an "Unusual Incident/Injury Report" form (LIC624)(to be completed by management staff only) be submitted immediately after certain types of events occur at ECS facilities. This procedure details the steps to be taken in initiating reporting.

Notify managers of any incident immediately by clicking here.

The "Unusual Incident/Injury Report" (to be completed by management staff only) can be downloaded by clicking here.

For ECS purposes, the Center Incident Notification (CIN) should be initiated by any staff member who obverses a potentially reportable incident involving any other staff member, any child or parent or other visitor to the facility. The types of events to be reported are detailed on form. They involve situations where there is any of the following:

Aggressive Acts
Abuse
Injuries
Medical Interventions
Property Damage
Sickness/Outbreak
Hazard
Other

Reporting Responsibilities

In some instances , The Unusual Incident Form LIC624 must be completed by the Family Services Manager after other reports, such as a "Suspected Child Abuse Report" (form SS 8572) have been filed with other agencies.

Form Instructions
1. Name of Facility - Center name
2. Facility File Number -- Not used
3. Telephone Number -- (209)533-0361 ext. 243 (Family Services Manager)
4. Address -- Center Address
5. City, State, Zip -- Center Address
6. Clients/Residents Involved -- Staff, Child, Parent or other Visitor
7. Date Occurred -- MM/DD/YYYY
8. Age -- Client's age, if known
9. Sex -- Client's sex, if known
10. Date of Admission -- Enrollment Date if applicable
11. Type of Incidence -- Check the box
12. Describe Event -- Clearly report all relevant elements of incident.
13. Person(s) -- List all witnesses of the event
14. Explain immediate actions -- Clearly report all relevant actions taken and by whom they were taken
15. Medical treatment? -- Check appropriate box and explain as needed
16. Where / Who administered -- Name of treating facility and person
17. Follow-up -- Identify any treatment planned
18. Action taken/planned -- Describe any corrective actions
19. Supervisor Comments -- To be completed by the Family Services Manager with input from the Lead Center Teacher
20. Attending Physician -- Name of doctor
21. Report submitted by -- Reporter's signature and title, date
22. Report reviewed -- Program Director's signature, date
23. Agencies notified -- Check all appropriate boxes and enter names and phone numbers
Form Distribution Instructions
1. The Unusual Incident Form LIC624 (to be completed by management staff only) is initiated from a Center Incident Notice (CIN) submitted by the original reporter in most cases. Note that immediate verbal reporting of the incident is essential.
2. The reporter should make three copies of the Center Incident Notice, distributing them as follows:
  1. place one in the Family section of the Child's File,
  2. give one to the site supervisor, and
  3. keep a personal copy.
3. The original form should be submitted via the internet by clicking the submit button at the bottom of the form, to the Service Area Managers at the Program Office.
4. The Service Area Managers will
  1. review the CIN for completeness and get any updated information as appropriate to explain or amplify the report.
  2. If deemed necessary, a LIC624 Unusual Incident Report will be filed
  3. The Program Director will review and sign the completed form, and fax the form within 24hrs to CCL.
  4. Then mail the signed form within 7 days of the occurrence of the incident.
  5. file the original in the Unusual Incident master file maintained at the Program Office.
5. Any subsequent correspondence or formal actions should be cross-referenced to the master file copy.

Edited 12/03/2007 12:04:54 PM