Get Lic 624

The Lic 624 form is an essential document for reporting unusual incidents or injuries in community care settings. This guide provides clear instructions for completing the form online, ensuring that you meet the necessary reporting requirements efficiently.

Follow the steps to successfully complete the Lic 624 form.

1. Press the ‘Get Form’ button to access the Lic 624 form and open it in your preferred editor.
2. Start by entering the name of the facility, followed by the facility file number, address, city, state, and ZIP code. Ensure all entered information is accurate and complete.
3. Provide the telephone number for the facility in the designated field.
4. List the clients or residents involved in the incident. Ensure clarity in documenting their names for proper identification.
5. Select the type of incident from the provided options. Options include unauthorized absence, aggressive acts, alleged client abuse, and other categories relevant to the occurrence.
6. Enter the date the incident occurred to maintain an accurate timeline.
7. Fill in demographic information such as the age and sex of the individuals involved in the incident.
8. Detail the incident in the description section. Include critical information such as the date, time, location, the nature of the incident, and any antecedents leading to it.
9. List the names of the persons who observed the incident or injury for accountability.
10. Explain the immediate actions taken in response to the incident, including details of any individuals contacted during the situation.
11. Indicate whether medical treatment was necessary by selecting 'yes' or 'no.' If 'yes', provide details regarding the nature of treatment, where it was administered, and by whom.
12. Document any follow-up treatment planned and actions taken or planned by relevant personnel, along with expected outcomes.
13. Include comments from the licensee or supervisor regarding the incident.
14. Finally, fill in the names and titles of the attending physician, as well as your name as the report submitter.
15. Complete the review and approval section, ensuring all notified agencies and individuals are documented with their names and phone numbers.
16. Once all information is accurately entered, save changes, and download or print the form as necessary to retain for records or submission.

Start filling out the Lic 624 form online to ensure timely reporting of incidents.