Fillable Form 7239: Incident or Illness Report Directions (Texas Real Estate Contracts)

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Form 7239: Incident or Illness Report Directions (Texas Real Estate Contracts)

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The Form 7239: Incident or Illness Report Directions (Texas Real Estate Contracts) form is 2 pages long and contains:

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The Texas Real Estate Commission (TREC) is an agency that governs real estate practices in the state of Texas USA. I its headquarters are located in Ausin Texas at 1700 North Congress.

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Form 7239
May 2021-E
Incident or Illness Report
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
Complete the form as follows:
• Injury requiring medical treatment or hospitalization: Complete all information in Sections I, II, V and VI.
• Incident that placed a child at risk: Complete all information in Sections I, II, V and VI.
• Illness requiring hospitalization: Complete all information in Sections I, III, V and VI.
• Incidence of a child or employee contracting a communicable disease: Complete all information in Sections I, IV, V and VI.
After completing the form:
• Notify parents as required by the minimum standards; and
• Keep the form on file at the operation.
Privacy Statement
HHSC values your privacy. For more information, read the privacy policy online at: https://hhs.texas.gov/policies-practices-privacy#security.
Section I – General Information
Director's Name: Operation No.: Date of Incident or Illness: Time of Incident or Illness:
a.m.
p.m.
Parent(s)* Notified: Yes No
*For communicable diseases, all parents must be notified.
Date: Time: By:
Child Care Regulation Notified: Yes No
Date: Time: By:
Section II – Details of Injury and/or Incident (Section not used for incidences of communicable disease or illnesses.)
Child's Full Name: Child's Date of Birth:
Caregiver in Charge:
Describe the injury or risk:
How did the incident or injury occur?
Additional staff present and/or witness to the incident or injury:
Was first aid provided? Yes No
What type of first aid was provided?
Was Emergency Medical Services (EMS) called?
Yes No
Time EMS was called:
Was child transported to receive medical care?
Yes No
Who transported the child?
Form 7239
Page / 05-2021-E
Section III – Illness Requiring Hospitalization (Section not used for incidents, injuries or notifications communicable disease.)
Child's Full Name: Child's Date of Birth:
Was first aid provided? Yes No
What type of first aid was provided?
Was medication given?
Yes No
Name of medication:
Dosage:
Did the child have a fever?
Yes No
Temperature:
Was medical treatment required?
Yes No
Date and time medical treatment received:
Was EMS called?
Yes No
Time EMS was called:
Was child transported to receive medical care?
Yes No
Who transported the child?
Was an allergy plan enacted?
Yes No N/A
What was done?
Was there an emergency anaphylaxis reaction that required administration of an unassigned epinephrine auto-injector?
Yes No
Was use of an unassigned epinephrine auto-injector reported to Texas Department of State Health Services (DSHS)? Yes No N/A
Date reported to DSHS:
Was the child’s doctor called by the operation?
Yes No
Doctor's Name: Doctor's Phone No.: Time doctor was called:
Doctor's recommendation(s):
Did the child see his or her doctor? Yes No
Diagnosis or Outcome:
Was hospitalization required?
Yes No
Additional Details:
Section IV – Communicable Disease (Section not used for incidents, injuries or illness other than communicable disease notification.)
Type of communicable disease contracted by child or employee at this operation:
Does the communicable disease require exclusion? Yes No
Was the Health Department notified? Yes No
Date Health Department notified:
Section V – Employee or Caregiver Certification
I verify that I, the director/person in charge, reviewed the information in this report.
Printed Name: Signature of Director or Person in Charge: Date Signed:
Section VI – Parent or Guardian Acknowledgment
I verify that the operation appropriately relayed the information concerning the incident described in this report. I have received a copy of this
report. (If emailed or distributed electronically, you may attach a copy of the method used.)
Printed Name: Signature of Parent or Guardian: Date Signed:
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Form 7239: Incident or Illness Report Directions (Texas Real Estate Contracts)

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Completed 10 February 2022

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