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Get Accident Incident State Of Michigan Report Bcal

INCIDENT REPORT STATE OF MICHIGAN Michigan Department of Human Services Bureau of Children and Adult Licensing Incident Accident Illness Death Fire Was the incident phoned to BCAL Yes No If no contact your licensing consultant within 24 hours of the incident. If yes date and time FACILITY Registration/License Number Facility Phone Number Facility/Home/Provider Name Address Street Number and Name County City State Zip Code CHILD REN IN CARE INVOLVED Name Birthdate Sex M Home Address Street Number Name Home Phone Number Name of Parent Alternative Phone Number CAREGIVER/OTHER PERSON S INVOLVED / WITNESS ES INCIDENT DETAILS Time BCAL-4605 7-12 MS Word Date Describe the incident. Be specific* F A. M. P. M. Location Was First Aid Given If yes when By Whom N/A Illness or Injury if applicable Where Child Received Medical Treatment if known Phone Number of Treating Physician Medical Facility Hospital if applicable Any Handicaps Health Problems or Exceptions Listed on the Child s Health Records if applicable If Fire Describe Damage PERSON S NOTIFIED Law enforcement fire marshal parent/legal guardian etc* Name of Person Notified Notification Date Signature of Person Completing This Report Title Signature of Registrant/Licensee/Responsible Person Department of Human Services DHS will not discriminate against any individual or group because of race religion age national origin color height weight marital status sex sexual orientation gender identity or expression political beliefs or disability. If you need help with reading writing hearing etc* under the Americans with Disabilities Act you are invited to make your needs known to a DHS office in your area* AUTHORITY COMPLETION PENALTY 1973 PA 116 Voluntary/Mandatory May be in violation of licensing rule. If yes date and time FACILITY Registration/License Number Facility Phone Number Facility/Home/Provider Name Address Street Number and Name County City State Zip Code CHILD REN IN CARE INVOLVED Name Birthdate Sex M Home Address Street Number Name Home Phone Number Name of Parent Alternative Phone Number CAREGIVER/OTHER PERSON S INVOLVED / WITNESS ES INCIDENT DETAILS Time BCAL-4605 7-12 MS Word Date Describe the incident. Be specific* F A. M. P. M. Location Was First Aid Given If yes when By Whom N/A Illness or Injury if applicable Where Child Received Medical Treatment if known Phone Number of Treating Physician Medical Facility Hospital if applicable Any Handicaps Health Problems or Exceptions Listed on the Child s Health Records if applicable If Fire Describe Damage PERSON S NOTIFIED Law enforcement fire marshal parent/legal guardian etc* Name of Person Notified Notification Date Signature of Person Completing This Report Title Signature of Registrant/Licensee/Responsible Person Department of Human Services DHS will not discriminate against any individual or group because of race religion age national origin color height weight marital status sex sexual orientation gender identity or expression political beliefs or disability.

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