Get Notification Of Injury Illness Or Critical Incident - Kdheks

Filling out the Notification Of Injury, Illness Or Critical Incident form is an important step in reporting incidents involving children in care programs. This guide provides clear, step-by-step instructions to ensure users can efficiently complete this form online.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in the online editor.
2. Enter the license number of the facility in the appropriate field.
3. Input the name of the facility exactly as it appears on the license.
4. Provide the street address of the facility.
5. Fill in the city where the facility is located.
6. Enter the date you are completing the form in MM/DD/YYYY format.
7. Select the county in which the facility operates.
8. Indicate the type of notification by checking the appropriate box for illness, injury, or critical incident.
9. In the section indicating who was involved, enter the first and last name of the child or youth affected.
10. Input the date of birth of the child or youth in MM/DD/YYYY format.
11. Provide the date and time of the incident in MM/DD/YYYY and HH:MM formats respectively.
12. Describe the injury, illness, or critical incident, including details about what happened and the location of the children at the time.
13. Document any actions taken by the facility in response to the incident.
14. Provide remarks regarding the child's initial appearance and condition after the incident.
15. Indicate whether medical attention was required, and if so, describe the response and if it occurred on site or at a clinic/hospital.
16. Complete the notes section by entering the date and comments or remarks.
17. List the first and last name of the adult(s) responsible and/or observing the incident and their relationship to the facility.
18. The individual completing this form must attest to the accuracy of the information by printing their name, signing, and entering the date of signature in MM/DD/YYYY format.

Complete your documentation online today to streamline the reporting process.