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The document is a Child Care Center Injury/Incident Report Form (DHS-4959-ENG) from the Division of Licensing, intended for notifying the Department of Human Services about specific incidents involving children in care. It outlines the requirements for reporting child deaths, injuries requiring medical treatment, fire incidents, and emergency medical service usage within specified timeframes. The form emphasizes the confidentiality of the information provided and includes instructions for reporting suspected child maltreatment.

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