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BCAL-4605 (-1) MS Word 1
INCIDENT REPORT
STATE OF MICHIGAN
Michigan Department of Licensing and Regulatory Affairs
Child Care and Camps
INSTRUCTIONS
COMPLETION AND SUBMISSION
The completion and submission of this form to the department is required by the
following licensing rules:
Family and Group Child Care Homes R 400.1962(2)
Child Care Centers R 400.8158(3)
Children's and Adult Foster Care Camps R 400.11127(9)
DISTRIBUTION
Send original to your licensing consultant and retain a copy for your records.
Was the incident phoned to licensing?
Yes If yes, date and time? ___________________
No
If no, contact your licensing consultant within
24 hours of the incident.
TYPE OF REPORT
Incident Accident Illness Death Fire
FACILITY
Registration/License Number Facility Phone Number Facility Type
( )
Family Child Care Home
Group Child Care Home
Child Care Center
Children’s Camp
Adult Foster Care Camp
Facility/Home/Provider Name
Address (Street Number and Name) County
City State Zip Code
CHILD(REN) IN CARE INVOLVED
Name Name
Birthdate Sex Birthdate Sex
M
F
M
F
Home Address (Street Number & Name) Home Address (Street Number & Name)
City State Zip Code City State Zip Code
Name of Parent Name of Parent
Home Phone Number Alternative Phone Number Home Phone Number Alternative Phone Number
( ) ( ) ( ) ( )
CAREGIVER(S) / OTHER PERSON(S) INVOLVED / WITNESS(ES)
Name Name
Address (Street Number, Name, City) Address (Street Number, Name, City)
Phone Number Phone Number
( ) ( )
INCIDENT DETAILS
Incident Date Time
A.M.
P.M.
Location
Describe the incident. Be specific.