California Family Child Care Home Incident Report

Submit the completed form to the local Child Care Licensing office via fax or email as per the reporting guidelines. Ensure to retain a copy of the submitted report for your records. If you need to clarify submission methods, refer to the applicable state regulations for the contact information.

Important dates for submitting incident reports in 2024 and 2025 will generally follow state guidelines after each incident. These reports should be filled out and submitted without delay to comply with legal standards. Adhere to any updates from local regulatory bodies regarding reporting timelines.

The purpose of this form is to ensure that all unusual incidents or injuries involving children in family child care homes are reported timely and accurately. It acts as a formal mechanism to document events that could impact child safety and health. By utilizing this form, child care providers can demonstrate adherence to state regulations and promote a safer environment for children.

• 1. Facility License Number: Unique identifier assigned to the child care facility.
• 2. Licensee Name: Name of the person or entity that holds the license.
• 3. Facility Name: Official name of the child care home.
• 4. Facility Address: Complete postal address of the facility.
• 5. Name of Children Involved: Full names of the children affected by the incident.
• 6. Birth Date/Age: The age or date of birth of the children involved.
• 7. Sex: Gender of each child specified as Male or Female.
• 8. Admission Date: The date each child was admitted to the facility.
• 9. Primary Language: Language spoken by the child or their family.
• 10. Event Reported: Details of the incident to be reported to authorities.
• 11. Incident Description: Narrative describing what happened during the incident.
• 12. Injury Details: Information pertaining to any injuries sustained.
• 13. Preventive Steps: Actions taken to prevent similar incidents in the future.
• 14. Health Care Provider Info: Contact information for any medical professionals involved.
• 15. Notification Date: Date when the child's parents were notified about the incident.
• 16. Agencies Notified: List of agencies that were informed about the incident.
• 17. Contact Person: Name of the representative contacted at each agency.
• 18. Submission Date: Date when the form is signed and submitted.

If this form is not submitted, there could be serious repercussions ensuring child safety. Failing to report incidents may lead to investigations and potential penalties. It is crucial to comply with state reporting regulations to avoid legal issues.

• Legal Penalties: There may be fines or other consequences for failing to report.
• Investigation Risks: Failure to report could prompt investigations by authorities.
• Increased Liability: Neglecting to submit could result in heightened liability risks.

• 1. Injury Reporting: Use this form to document any injuries sustained by children.
• 2. Incident Notification: Required for reporting incidents involving absences or allegations of abuse.
• 3. Regulatory Compliance: Necessary for compliance with state and local regulations.