Fillable Printable Death Report Form - California

Death Report Form - California

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

COMMUNITY CARE LICENSING DIVISION

DEATH REPORT

LICENSEE MUST REPORT THE DEATH OF A CLIENT

OF ANY CAUSE, REGARDLESS OF WHERE THE

DEATH OCCURRED.

INSTRUCTIONS : NOTIFY LICENSING AGENCY, PLACEMENT AGENCY AND

RESPONSIBLE PERSONS, IF ANY, BY NEXT WORKING DAY.

SUBMIT WRITTEN REPORT WITHIN 7 DAYS OF OCCURRENCE.

RETAIN COPY OF REPORT IN CLIENT’S FILE.

NAME OF FACILITY FACILITY FILE NUMBER

CITY, STATE, ZIP

D.O.B.

DATE AND TIME OF DEATH

DESCRIBE IMMEDIATE CAUSE OF DEATH (IF CORONER REPORT MADE, SEND COPY WITHIN 30 DAYS):

DESCRIBE CONDITIONS PRIOR TO OR CONTRIBUTING TO DEATH:

EXPLAIN WHAT IMMEDIATE ACTION WAS TAKEN (INCLUDE PERSONS CONTACTED):

MEDICAL TREATMENT NECESSARY?

■■ YES ■■ NO IF YES, GIVE NATURE OF TREATMENT:

PLACE OF DEATH

SEX DATE OF ADMISSION

TELEPHONE NUMBER

( )

ADDRESS

CLIENT’S NAME

LIC 624A (7/99)

NAME OF ATTENDING PHYSICIAN

REPORT SUBMITTED BY:

REPORT REVIEWED/APPROVED BY:

NAME OF MORTICIAN

NAME AND TITLE

DATE

AGENCIES/INDIVIDUALS NOTIFIED (SPECIFY NAME AND TELEPHONE NUMBER)

■■ LICENSING______________________________________ ■■ ADULT/CHILD PROTECTIVE SERVICES________________________

■■ LONG TERM CARE OMBUDSMAN___________________ ■■ PARENT/GUARDIAN/CONSERVATOR__________________________

■■ LAW ENFORCEMENT_____________________________ ■■ PLACEMENT AGENCY______________________________________