INSTRUCTIONS : UNUSUAL INCIDENT/INJURY - CDSS Public Site
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING DIVISION
UNUSUAL INCIDENT/INJURY REPORT
NAME OF FACILITY
ADDRESS
INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY.
SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE.
RETAIN COPY OF REPORT IN CLIENT'S FILE.
FACILITY FILE NUMBER CITY, STATE, ZIP
TELEPHONE NUMBER
I (
)
CLIENTS/RESIDENTS INVOLVED
DATE OCCURRED
AGE SEX
DATE OF ADMISSION
TYPE OF INCIDENT Unauthorized Absence Aggressive Act/Self Aggressive Act/Another Client Aggressive Act/Staff Aggressive Act/Family, Visitors Alleged Violation of Rights
Alleged Client Abuse Sexual Physical Psychological Financial Neglect
Rape Pregnancy Suicide Attempt Other
Injury-Accident Injury-Unknown Origin Injury-From another Client Injury-From behavior episode Epidemic Outbreak Hospitalization
Medical Emergency Other Sexual Incident Theft Fire Property Damage 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):
LIC 624 (4/99)
OVER
MEDICAL TREATMENT NECESSARY?
YES
NO
IF YES, GIVE NATURE OF TREATMENT:
WHERE ADMINISTERED: FOLLOW-UP TREATMENT, IF ANY:
ADMINISTERED BY:
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______________________________________ LONG TERM CARE OMBUDSMAN___________________ LAW ENFORCEMENT_____________________________
ADULT/CHILD PROTECTIVE SERVICES________________________ PARENT/GUARDIAN/CONSERVATOR__________________________ PLACEMENT AGENCY______________________________________
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