CA HHSA LIC 624 1999-2024 free printable template

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 ADDRESS CITY STATE ZIP TELEPHONE NUMBER CLIENTS/RESIDENTS INVOLVED TYPE OF INCIDENT s Unauthorized...

How to fill out lic 624 form

How to fill out LIC 624:

1. First, gather all the necessary information including personal details, contact information, and employment details.
2. Fill out the applicant information section accurately, providing your full name, address, phone number, and social security number.
3. Proceed to the employment information section and enter the details of your current or previous employment, including the employer's name, address, and phone number.
4. In the job information section, specify your position or job title, employment start and end dates, and any other relevant details.
5. If you have worked for multiple employers, make sure to provide this information for each one.
6. Next, move on to the employee representative information section and include the name, address, and contact details of any representative you have appointed.
7. In the certification section, read the statements carefully and sign and date the form to confirm the accuracy of the information provided.
8. Finally, review the completed form to ensure all information is correct and legible before submitting it.

Who needs LIC 624:

1. Individuals who are applying for employment or have been employed in California may need LIC 624.
2. It is specifically required for certain positions where the employee will be represented by a labor organization.
3. Employers and employees in industries covered by the Labor Code may also require LIC 624 compliance.

Please note that the LIC 624 form may be subject to specific industry or organization requirements, so it is advised to consult with relevant authorities or legal counsel for accurate guidance.

People Also Ask about lic 624

What are unusual incident injury report form used for?

Form LIC 624, Unusual Incident/Injury Report, is an document created for daycare providers that allows them to report unusual incidents and/or injuries to the appropriate California state agencies.

What is an example of an unusual incident?

UNUSUAL EVENT OR INCIDENT: Unusual incidents include resident abuse, unexplained absences, or anything that affects the physical or emotional health or safety of any resident and epidemic outbreaks, poisonings, catastrophes, facility fires or explosions.

What is an unusual occurrence incident report?

The unusual occurrence report is a guide to walk through a thorough investigation for a root cause analysis. An unusual occurrence report is to be completed for all injuries/accidents or any situation/occurrence that could pose a safety risk to patients or staff.

What is LIC 624?

LIC 624 - Unusual Incident/Injury Report.

Which of the following is an unusual incident?

Unusual Incident means incidents involving serious illness or accidents, death of an individual, injury or illness of an individual requiring inpatient or emergency hospitalization, suicide attempts, a fire requiring the services of a fire department, an act of physical aggression, or any incident requiring abuse

What is an example of unusual occurrence?

Unusual Occurrence means events or situations that do not happen daily or that may have had an impact on children. such as: fire drill interrupted sleep, visitor came with puppets, fear of a dog on a walk. It may by something that happened to the whole group of children or just to an individual child.

For pdfFiller’s FAQs

Who is required to file lic 624?

The LIC 624 form is used to report the payment of wages to non-residents for services performed in India. It must be filed by the employer in India who has made the payment.

How to fill out lic 624?

To fill out the Lic 624 form, you must first download the form from the State of California Department of Insurance website. Once downloaded, you will need to complete the form by providing your business information, including your business name, address, contact information, and any other relevant information. Once complete, you must sign and date the form and have it notarized.

What is the purpose of lic 624?

Lic 624 is a mandatory course for all students enrolled in the Master of Science in Cyber Security program at Johns Hopkins University. The course is designed to provide a comprehensive understanding of the principles of cyber security, including the fundamentals of cryptography, network security, and secure software development. It also covers topics such as secure systems design, incident response, and secure system administration.

When is the deadline to file lic 624 in 2023?

The deadline to file LIC 624 for the 2023 tax year is April 15, 2023.

What is the penalty for the late filing of lic 624?

The penalty for late filing of LIC 624 is a flat fee of $25 for each month it is late.

What is lic 624?

LIC 624 typically refers to a form used in the state of California by the Department of Social Services Community Care Licensing Division. This form, known as LIC 624, is used for reporting incidents and accidents that occur in licensed community care facilities such as residential care facilities for the elderly or child care centers. The form collects information about the incident, the individuals involved, and any actions taken.

What information must be reported on lic 624?

Lic 624 is a form required by the California Department of Social Services (CDSS) for licensed residential care facilities for the elderly (RCFE). This form is used to report any unusual incidents or suspected abuse occurring at the facility. The information that must be reported on Lic 624 includes: 1. Facility Information: Name, license number, address, and phone number of the RCFE. 2. Resident Information: The resident's name, age, gender, admission date, room number, and contact information. 3. Incident Information: Detailed description of the incident, including the date, time, location, and a factual account of what occurred. 4. Witness/Complainant Information: Name and contact information of any witnesses or individuals reporting the incident. 5. Alleged Perpetrator Information: If applicable, the name, position, and contact information of any staff member or other individual accused of the incident. 6. Type of Incident: Indicate the type of incident, such as physical abuse, verbal abuse, neglect, financial exploitation, sexual abuse, self-neglect, or unexplained injury. 7. Actions Taken: Describe any immediate actions taken in response to the incident, such as contacting law enforcement, seeking medical attention for the resident, or removing the alleged perpetrator. 8. Notification: Record if the incident has been reported to the appropriate law enforcement agency and any other relevant agencies, such as Adult Protective Services or Community Care Licensing. 9. Reporting Party Information: Name, position, and contact information of the person completing the form. 10. Signature: The form must be signed and dated by the reporting party. It is important to note that the completion and submission of Lic 624 is mandatory for licensed RCFEs in California whenever an unusual incident or suspected abuse occurs.

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Use the pdfFiller app for Android to finish your lic 624 le form. The application lets you do all the things you need to do with documents, like add, edit, and remove text, sign, annotate, and more. There is nothing else you need except your smartphone and an internet connection to do this.