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State of California — Health and Human Services Agency

Department of Health Care Services

Licensing and Certification Branch, MS 2600

PO Box 997413

Sacramento, CA 95899-7413

UNUSUAL INCIDENT/INJURY/DEATH REPORT

Instructions: The licensee shall make a telephonic report to the Department of Health Care Services Complaints and Counselor

Certification Division at (916) 322-2911 within one (1) working day for any of the following events: 1) Death of any resident

from any cause – even if death did not occur at facility. 2) Any facility related injury of any resident which requires medical

treatment. 3) All cases of communicable disease reportable under Section 3125 of the Health and Safety Code or Section 2500,

2502, or 2503 of Title 17, California Administrative Code shall be reported to the local health officer in addition to the

Department. 4) Poisonings. 5) Natural disaster. 6) Fires or explosions which occur in or on the premises. The telephonic

report is to be followed by a written report to the Department within seven (7) days of the event [Regulations Section 10561].

Unusual Incident or Injury reports must be submitted to your Licensing Analyst. Death Reports must be submitted by fax to

the Complaints and Counselor Certification Division at (916) 445-5084 or by email to: DHCSLCBcomp@DHCS.ca.gov. Please

contact the Complaint Intake Coordinator at the toll free number (877) 685-8333 with any questions regarding submitting this form.

NAME AND SIGNATURE OF PERSON REPORTING INCIDENT:

NAME AND SIGNATURE OF AUTHORIZED REPRESENTATIVE:

FACILITY NAME AND LICENSE NUMBER:

FACILITY ADDRESS:

TELEPHONE NUMBER:

RESIDENT INFORMATION (Name, Age, Sex and Admission Date):

Complete in report Sections I, II and/or III as appropriate.

I. UNUSUAL EVENT OR INCIDENT: Unusual incidents include resident abuse, unexplained absences, or anything that affects the physical or emotional

health or safety of any resident and epidemic outbreaks, poisonings, catastrophes, facility fires or explosions. Describe event or incident including date,

time, location and nature of event. List what immediate action was taken (include persons contacted and if injury occurred complete Section II). Describe

what follow-up action is planned (include steps taken to prevent reoccurrence).

II. INJURY REQUIRING MEDICAL TREATMENT. Describe how and where injury occurred. What appears to be the extent of the injuries? List persons

who observed the injury. Name the attending physician, findings, and treatment.

III. DEATH REPORT. Date and time of death. Place of death. Describe immediate cause of death (if coroner report was made, send copy within 30 days).

What were conditions contributing to death? What actions were taken?

Name of Attending Physician

Name of Mortician

DHCS_5079 (07/13)