Fillable REPORT UNUSUAL INCIDENT/INJURY (University of California, San Francisco)

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REPORT UNUSUAL INCIDENT/INJURY (University of California, San Francisco)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
UNUSUAL INCIDENT/INJURY
REPORT
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.
NAME OF FACILITY FACILITY FILE NUMBER
CITY, STATE, ZIP
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):
TELEPHONE NUMBER
( )
ADDRESS
CLIENTS/RESIDENTS INVOLVED DATE OCCURRED
AGE SEX DATE OF ADMISSION
LIC 624 (4/99)
TYPE OF INCIDENT
■■ Unauthorized Absence Alleged Client Abuse ■■ Rape ■■ Injury-Accident ■■ Medical Emergency
■■ Aggressive Act/Self ■■ Sexual ■■ Pregnancy ■■ Injury-Unknown Origin ■■ Other Sexual Incident
■■ Aggressive Act/Another Client ■■ Physical ■■ Suicide Attempt ■■ Injury-From another Client ■■ Theft
■■ Aggressive Act/Staff ■■ Psychological ■■ Other ■■ Injury-From behavior episode ■■ Fire
■■ Aggressive Act/Family, Visitors ■■ Financial ■■ Epidemic Outbreak ■■ Property Damage
■■ Alleged Violation of Rights ■■ Neglect ■■ Hospitalization ■■ Other (explain)
OVER
MEDICAL TREATMENT NECESSARY? ■■ YES ■■ NO IF YES, GIVE NATURE OF TREATMENT:
NAME OF ATTENDING PHYSICIAN
REPORT SUBMITTED BY:
REPORT REVIEWED/APPROVED BY:
NAME AND TITLE
NAME AND TITLE
DATE
DATE
AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER)
■■ LICENSING______________________________________ ■■ ADULT/CHILD PROTECTIVE SERVICES________________________
■■ LONG TERM CARE OMBUDSMAN___________________ ■■ PARENT/GUARDIAN/CONSERVATOR__________________________
■■ LAW ENFORCEMENT_____________________________ ■■ PLACEMENT AGENCY______________________________________
WHERE ADMINISTERED: ADMINISTERED BY:
FOLLOW-UP TREATMENT, IF ANY:
ACTION TAKEN OR PLANNED (BY WHOM AND ANTICIPATED RESULTS:
LICENSEE/SUPERVISOR COMMENTS:
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REPORT UNUSUAL INCIDENTINJURY (University of California, San Francisco)

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Completed 16 June 2021

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