Meaning that it is accessible to the individual who is the subject of the data but not to the general public. Use this form to notify the Department of Human Services, Division of Licensing within: 24 hours of the death of a child in care in the center 24 hours of any injury to a child in care in the center that required treatment by a physician 48 hours of the occurrence of a fire during the hours of operation that required the service of a fire department 24 hours of the use o.
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How to fill out the MN DHS-4959-ENG online
The MN DHS-4959-ENG is the Child Care Center Injury/Incident Report Form designed for reporting significant events in a child care setting. This guide will walk you through the process of completing this form online, ensuring clarity and compliance.
Follow the steps to complete the MN DHS-4959-ENG online form
- Press the ‘Get Form’ button to acquire the form and open it in your preferred digital editor.
- Fill in the name of the program in the designated field.
- Enter the program license number in the corresponding section.
- Provide the address of the child care center.
- Include the name of the licensor overseeing the program.
- Record the date of the report submission.
- Specify the date when the injury or incident occurred.
- Document the date the program was notified of any medical or dental care that was provided.
- Indicate the time of day when the injury or incident took place.
- Write the name of the child involved in the incident.
- State the age of the child.
- Describe the incident in detail, covering how it happened, what occurred, and where it took place.
- Outline the action taken in response to the incident.
- Identify to whom the incident was reported.
- Conclude by including your name and title as the person completing the report.
- Once all fields are filled out, review the form for accuracy. Users can then save changes, download, print, or share the completed form as needed.
Begin completing the MN DHS-4959-ENG online today!
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