Licensing incident report 5 %µµµµ 1 0 obj >>> endobj 2 0 obj > endobj 3 0 obj >/ExtGState >/XObject >/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 Veteran-Friendly Employer. Licensing Notebook Summary Sheet - CCL-5052 - PDF. LICENSING RULES FOR AFC FAMILY HOMES & SMALL/LARGE GROUP HOMES. 5. 3. If the provider is licensed or certified by OL, submit a critical incident report through the OL Provider Portal within 1 business day of the incident occurrence. Help us protect Louisiana's children. Licensing Reports. texas. An Incident Report form must be completed and submitted in accordance with the standards set BCAL-4607-Fillable, AFC Licensing Division - Incident/Accident Report Author: Michigan Department of Human Services Subject: AFC Licensing Division - Incident/Accident Report Keywords: BCAL, AFC, Licensing, Incident, Accident Created Date: 4/11/2017 8:04:53 AM No If no, contact your licensing consultant within 24 hours of the incident. of. R. May 19, 2025 · Regardless of a lack of mandatory reporting requirements, every state has a licensing authority that will record incidents of injury, abuse, and neglect suffered by a child while in the care of a childcare facility. Submit incident reports to Licensing Direct using our direct reporting portal. Request for Electronic Incident Reporting February 2018 Page 4 of 4 Website: Community Care Facilities Licensing A new incident form will open. ca. Pre-register for attendance, by clicking the link for the corresponding date in the Incident . name of facility . This form may be used for Drop in Programs reporting to KDHE. Please ensure that you keep a copy of the completed Child Abuse/Neglect Hotline. Do not wait for the results of the evaluation to make the report if it will put you out of compliance with regulations. head injury. Name of Child: Date of Incident: Time of Incident: Name of Staff Writing Report: Name of Staff That Notified the Parent: Name of Parent: Date Parent Notified: Other Individuals Involved: ( i. New Incident Report Form for Programs – Licence holders are required to report serious illness, injury to a child, or any other incident that occurs while the child is attending a program that may seriously affect the health or safety of the child. gov Submit Incident/Accident Report using the online form. Licensing Rules require all child care facilities to make a verbal report to the department within 24 hours of a serious injury, accident, illness, or medical treatment or hospitalization at a health facility, or which results in a death. 6. Type of Report: Initial Final Initial/Final. - ) COPY DISTRIBUTION: Resident Record, Licensing Consultant, LIC 624B (8/08) - Unusual Incident/Injury Report - Family Child Care Home LIC 624 LE (12/22) - Law Enforcement Contact Report LIC 625 (10/24) – Appraisal/Needs and Services Plan Bureau of Child Care Licensing Incident – Injury Report CDC or SGH#:_____ G:\Forms\Incident-Injury Report (12/18) Page 1 of 4 This form is intended to help the facility document an injury that required emergency medical attention or hospitalization for a child. All other forms on this page are intended to assist the licensee in demonstrating compliance with the record keeping requirements specified in the Adult Foster Care Licensing Rules. A FC LICENSING DIVISION - INCIDENT / A CCIDENT REPORT Michigan Department of Licensing and Regulatory Affairs OTHER PERSON(S) INVO L VED / WITNESSES: F A CTS OF THE INCIDENT ( A T T ACH ADDITIONAL P AGES AS NEEDED ): PERSON(S) NOTIFIED: SIGN A TURE(S): BCAL-4607 (Re v. Many parents don’t know that they can report the incident themselves. Please view the DHHS Incident Reporting Guide to assist in understanding what constitutes an incident, what needs to be reported, and how it should be reported and documented. Tips for a successful submission: Use Microsoft Edge, Google Unusual Incident or Injury reports must be submitted to your Licensing Analyst. Child. Become familiar with reporting requirements that apply to you. All incident reports must be sent via email to licensingconnect@northernhealth. This incident should also be reported as a Level II serious incident for Individual #2 because that person sustained a serious injury. injury: (check all that apply ) ache breathing shallow . ) Sep 5, 2024 · The B. There are many forms and publications to help child care providers run a child care business in Wisconsin. instructions : notify licensing agency, placement agency and responsible persons, if any, by next working day. scrape be followed up with this report within 1 week. I don't think licensing will do anything major since he put in his report that he could see on camera that the entire incident was under 5 minutes, the steps we usually take to prevent this type of stuff, and our plan to make sure this doesn't happen again. Report Child Abuse & Neglect and Juvenile Sex Trafficking: 1-855-4LA-KIDS (1-855-452-5437) toll-free, 24 hours a day, seven days a week. Monitor and inspect facilities on a routine basis. Public Service acknowledges the territories of First Nations around B. (Ord. Escape Site TDD Access: Relay NH 1-800-735-2964. Specialized Investigation Unit (DD Deaths/MRC) Resources. You may reinstate your license online HERE. New Hampshire Child Care Licensing Injury / Incident Report 1. As a mandated reporter, The Division of Licensing & Certification (DLC) provides regulatory oversight of medical and long-term care facilities in Maine. center name: center address: child’s name: person completing report: witness(es): date . Licensing officers do the following: Issue licences to community care facilities. Inspection Reports & Illegal Operators Community Care Reportable Incident Form; Licensing; If the incident is an outbreak or service delivery problem and has Veteran-Friendly Employer. The goal of this process is to review the licensee’s actions to determine whether there is a recurring pattern, and to prevent a similar occurrence in the New Incident Report Form for Programs – Licence holders are required to report serious illness, injury to a child, or any other incident that occurs while the child is attending a program that may seriously affect the health or safety of the child. Incident Report CCL-4605 - Word. and is grateful to carry out our work on these lands. r:\program support\licensing\ccl\group\rules\4002 child care rules\2016 cc rules \forms\injury report. injury: date report completed: time report completed: type . Incident Report Document: cclu-incidentreport. Suspended/cancelled licenses - $100; Revoked licenses - $175; Alcohol/drug-related offenses: Forms marked with a (*) are required and must be used unless prior written approval for a specific substitute form has been granted. Parent Notification of the Licensing Notebook CCL-5053 PDF. e. Office of Licensing Incident Management 101 Training (April 2025) Risk Mitigation Tool for Serious Incident Reports (October 2024) Serious Incident Reporting-Covid-19 (December 2022) Individual and Systematic Risk – How to Report and Respond to Incidents (April 2022) LIC 624, Unusual Incident/Injury Report (PDF; 78. community care licensing division . submit written report within 7 days of occurrence. LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. Enter the licensee’s name as shown on license. Copy of Crash Report - $15; Crash Reports may be purchased online HERE or in person at any ALEA Driver License Office. %PDF-1. We acknowledge the rights, interests, priorities, and concerns of all Indigenous Peoples - First Nations, Métis, and Inuit - respecting and acknowledging their distinct cultures, histories, rights, laws, and governments. Was the incident phoned to licensing? Yes No If no, contact your licensing consultant within Section 55 of the Child Care Licensing Regulation and Section 76 & 77 of the Residential Care Regulation; set out requirements for notification of illness, injury and reportable incidents in licensed care facilities. UNUSUAL INCIDENT REPORT . Regulatory Chapter 2600 2800 Name of Legal Entity : Name of licensed setting as it appears on license: Welcome to the Community Care Licensing Division. From policy samples to incident reports, enrollment forms, background checklists, and more, you'll find a variety of resources to help you. 8158(3) Children's and Adult Foster Care Camps R 400. Report It. C Quarterly Licensing Report Early Learning & Child Care 5 Steps to Selecting Child Care Assisted Living Residences — Reportable Incident Form — effective Oct To ensure Child Care Regulation can investigate this incident, please at least provide the provider’s zip code. The purpose of reporting an incident is: To ensure that incidents are reported and reviewed in a timely manner both by the community and Community Care Facilities Licensing staff. Submit a completed form to the regional licensing / certification office. 21 KB) LIC 624 (SP), Reporte de incidente inusual o lesión (pdf; 80. Footer During inspections, licensing officers look for items typically divided into ten broad categories: Physical facility, equipment and furnishings; Staffing; Policies and procedures; Care and/or supervision; Nutrition and food services; Medication; Hygiene and communicable disease control; Records and reporting; Licensing administration; Program Submit an Accident/Incident Report (Indicate Type of Report, and Enter License Number) Please include '-' between license prefix and suffix (Example: ABC-1234). Please ensure you submit a copy of the completed Incident Report form to your funding program if applicable. 28-4-133 and K. Operations use this form to record all required information when a child sustains an injury, at the onset of an illness or reportable incident. Directions . SERIOUS INCIDENT REPORTING AND CHRIS TRAINING. pdf. A reportable incident is an event where a child has been injured, been harmfully affected or gone missing while under the care and supervision of the licensee. We serve the most vulnerable people of California and our mission is to promote the health, safety, and quality of life of each person in community care through the administration of an effective and collaborative regulatory enforcement system. retain copy of report in client’s file. Death Reports must be submitted by fax to the Complaints and Counselor Certification Division at (916) 440-5094 or by email to: DHCSLCBcomp@DHCS. C. facility file number . 2 All data are based upon incidents reported to Child Care Licensing. This video provides helpful answers to the following questions: What reports am I required to submit to Licensing? working day. Produced by the Community Care Licensing Division of the California Department of Social Services [music] [Onscreen, a provider fills out an injury report. Incident Report paper forms can be obtained from any Island Health Licensing office location or from your Licensing Officer and can be submitted to Licensing by email or by fax. doc Revised 01/2019 . This process will assist in the prevention of recurrence and in the promotion of a high standard of care, safety, health and dignity of the persons in care. injury: time . Signed copy to parent. Reports being Sep 5, 2024 · Inspection reports will not: Recommend a facility to you; Rank or rate facilities against one another; Issue a report card that grades facilities; Provide personal information about children in care; It is important not to draw conclusions about the quality of a facility based only on the information contained in the inspection report. 11127(9) DISTRIBUTION Send original to your licensing consultant and retain a copy for your records. Request for Modification of the Terms of the License - CCL-5054 - PDF. Parent Notification of the Licensing Notebook CCL-5053 - Word. 58 KB) Updated November 2022, UCSF California Childcare Health Program The Incident Report LIC 624 form is a crucial document used by the California Department of Social Services Community Care Licensing Division. Management 101 Training Schedule below. Reinstatement Fees. Enter the number and street address, city, and zip code. resulting in an injury. Description: Residential Child Care Licensing & Forms. TYPE OF REPORT Incident Accident Illness Death Fire FACILITY License Number Facility Phone Number Facility Type Family Child Care Home Group Child Care Home Child Care Center Facility/Provider Name Address (Street Number and Name) County City State Zip Code N/A = Data not available. foreign body in e ye. Complete the form as follows: • Injury requiring medical treatment or hospitalization: Complete all information in Sections I, II, V and VI. Incident Reporting Form . The Community Care and Assisted Living Act provides the Director of Licensing with specific powers, as well as with the ability to specify policies and standards for practice for community care facilities. Enter in all required information into the form and then select ‘Save’. 1416a Incident notification, incident records. Enter the facility number as shown on the license 2. 1962(2) Child Care Centers R 400. • See full list on hhs. following licensing rules: Family and Group Child Care Homes R 400. Submittal to the Department is not required. telephone number ( ) address Incident or Illness Report. FAMILY HOME: R 400. Enter the first and last name of each child involved in the incident or injury. It is designed for reporting unusual incidents or injuries that occur within licensed care facilities, detailing steps taken immediately after the incident and specifying follow-up actions. A. Facility Information. Stop Child Abuse - Contact the Abuse Hotline 1-800-962-2873. Resilient Environment Department Consumer Protection Division . The Child Care Reporting Requirements. 2004-02, § 1, 2-10-04) 4. Child Care Licensing Forms & Publications. Submit a reportable incident. All reports must be maintained for 3 years, on site, in a separate file. You must also complete the Unusual Incident Report (UIR) LIC 624 for centers or LIC 624b for family child care homes within one business day. BCAL-4607-Fillable, AFC Licensing Division - Incident/Accident Report Author: Michigan Department of Human Services Subject: AFC Licensing Division - Incident/Accident Report Keywords: BCAL, AFC, Licensing, Incident, Accident Created Date: 9/9/2009 7:06:38 AM Form 2971, Child Care Licensing Request for Background Check (English and Spanish) Form 2982, Personal History Statement Form 2985, Affidavit for Applicants for Employment with a Licensed Operation or Registered Child-Care Home (English and Spanish) Community care facility licensing protects and promotes the health, safety and well-being of vulnerable children and adults in licensed care facilities. Bureau of Human Services Licensing . Enter the name of the facility as shown on the license. Child care licensees are responsible for submitting reports to Community Care Licensing, as well as other agencies. If known, you can input the provider name, operation number, or address. Please contact the Complaint Intake Coordinator at the toll free number (877) 685-8333 with any questions Sep 2, 2015 · The Director of Licensing is appointed by the Minister of Health and is responsible for overseeing community care licensing in BC. redness bitten by animal broken bone suspected . Licensed or certified Texas Health and Human Services providers must notify the agency if someone in their care has been or may be physically or mentally abused, neglected or exploited. Licensing Notebook Summary Sheet - CCL-5052 - Word. Nov 28, 2020 · Level II serious incident for Individual #1 because that person caused significant harm to another individual. 28-4-592. The timeframe for reporting begins as soon as the center / provider is aware of the medical evaluation, death, or injury caused by an animal. Provider Name or Operation Number No If no, contact your licensing consultant within 24 hours of the incident. Muaj ntau hom ntaub ntawv ua lus Hmoob. gov. Alabama Code 32-10-7 governs who is eligible to purchase crash reports. The provider is also required to report the incident for Individual #2 to the Office of Bureau of Human Services Licensing Incident Reporting Form Type of Report: Initial Final Initial/Final FACILITY INFORMATION REGULATORY CHAPTER: 2380 2390 2600 2800 3800 6400 6500 NAME OF LEGAL ENTITY: NAME OF LICENSED SETTING AS IT APPEARS ON LICENSE: FACILITY ADDRESS: LICENSE NUMBER: PHONE NUMBER: INCIDENT INFORMATION A licensing officer investigates the incident report to assess the factors that led to the incident, as well as the appropriateness of the licensee’s response and corrective actions. Other Staff/Adults, Witnesses, Children ( Described as Child #1, Child #2, etc. No. This includes oversight of the CNA registry, criminal background checks for employers to ensure staff are safe to care for our vulnerable citizens, and investigations into allegations of unsafe practices/events in facilities as diverse as hospitals, nursing homes The local licensing agency shall be notified as soon as possible, but no later than within one (1) work day, in the event of an illness, accident, injury, or emergency that results in the serious injury or death of a child in care. We do this through education, collaboration and regulation. TYPE OF REPORT Incident Accident Illness Death Fire FACILITY License Number Facility Phone Number Facility Type Family Child Care Home Group Child Care Home Child Care Center Facility/Provider Name Address (Street Number and Name) County City State Zip Code This form, for License and Group Day Care Homes, Child Care Centers and Preschools, and School Age Programs is to be used when reporting an injury, death, critical incident or occurrence that jeopardizes the safety of any child in care pursuant to K. Submit Incident/Accident Report using the fillable form by mail, fax or email to the licensing staff member requesting the report. Reporting Expectations. 4. unusual incident/injury report . The report should include the following: Inspection Checklist - Pre-Licensing - State Form 49450; Inspection Checklist Proposed - State Form 52087; Injury Report Child - State Form 54265; Kitchen Cleaning Schedule - Center; Licensed Center Inspection Checklist - State Form 46153; Manual Dishwashing Procedure (Posting) Menu for infants (8-12 months) - State Form 49951 Stand Up for Children. You must immediately notify your local CDSS Child Care Licensing Regional Office by email or phone during normal business hours. Form 7239, Incident or Illness Report Instructions for Opening a Form Some forms cannot be viewed in a web browser's PDF viewer and must be opened in the Adobe Reader application on your desktop system. Creating an Individual ID, Creating and Updating a New Death and Serious Incident Report. ] Series Host: As a licensed child care provider, you are required to submit reports to Community Care Licensing so that the records of your business are always current. kfbsm difajy naeyhbu tdpa diekbb bftol kye rbra dewpu jydsm