DHS-4959-ENG-2026

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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 reporting specific incidents involving children in care. It outlines the requirements for notifying the Department of Human Services within set timeframes regarding child deaths, injuries requiring medical treatment, fire incidents, and emergency medical services. The form emphasizes the confidentiality of the information provided and includes instructions for reporting suspected child maltreatment.

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Click ‘Get Form’ to open the DHS-4959-ENG in the editor.
Begin by entering the 'Name of program' and 'Program license number' at the top of the form. This identifies your child care center.
Fill in the 'Address' and 'Name of licensor' fields to provide contact information for your licensing authority.
Record the 'Date of report', 'Date of injury/incident', and 'Date program notified of medical or dental care'. Accurate dates are crucial for compliance.
Indicate the 'Time of day injury/incident occurred' to give a clear timeline of events.
Enter the 'Name of child' and their 'Age'. This personalizes the report and ensures it pertains to the correct individual.
In the section labeled 'Describe what happened (how, what, where)', provide a detailed account of the incident. Clarity is key here.
Document any actions taken in response to the incident in the 'Action taken' field.
Finally, specify 'To whom it was reported' and complete with your name and title in the 'Report completed by' section.

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2010	4.5 Satisfied (21 Votes)

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