Form LIC 624B Unusual Incident/Injury Report For Family Child ... 2026

1. Start by clicking ‘Get Form’ to open the LIC 624B in our editor.
2. Fill in today’s date at the top of the form, followed by the facility name and license number.
3. Enter the licensee’s name and facility address accurately to ensure proper identification.
4. List the names and birth dates of each child involved in the incident, along with their gender and primary language.
5. Document the date and time of the incident or injury, as well as when parents were notified.
6. Select the type of incident or injury from the provided options, ensuring you check all that apply.
7. Provide a detailed description of what happened and any injuries sustained, including physician details if applicable.
8. Indicate how this incident will be prevented in the future and list any agencies notified about the incident.
9. Complete your contact information at the bottom of the form before submitting it for review.

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