Staff reporting

Incident & death reports.

Complete the official LIC 624 or LIC 624A, print it, and send a copy to the APCH team automatically.

For staff use. This page completes the state forms and emails a copy (PDF attached) to David & Colin. The report includes resident details, so only complete it on a trusted device. Per LIC requirements, notify Licensing by the next working day and submit the written report within 7 days.

Step 1

Report type & home

Report *

Home *

Step 2

Client / resident involved

Name of client/resident *

Date occurred

Age

Sex

Date of admission

Step 3

Type of incident

Step 4

What happened

Describe the event/incident (time, date, location, perpetrator, nature, antecedents, how clients were affected, any injuries)

Person(s) who observed the incident/injury

Immediate action taken (include persons contacted)

Step 5

Medical treatment

Medical treatment necessary?

Yes No

If yes, nature of treatment

Where administered

Administered by

Follow-up treatment, if any

Action taken/planned, by whom and anticipated results

Attending physician

Report ready

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Open & print PDF Download PDF

Incident & death reports.

Report type & home

Client / resident involved

Type of incident

What happened

Medical treatment

Client

Details

Medical & mortician

Submitted by & agencies notified

Report ready