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Get Ca Lic 624b 2003

N, or authorized representatives of child(ren) in care. 2. Notify Licensing by telephone, fax, or e-mail before end of next working day. 3. If reported by telephone, submit written report within 7 calendar days of the incident/injury to Licensing. 4. Keep a copy of the report in the child’s facility file. 1. TODAY’S DATE 4. FACILITY NAME: 6. 2. FACILITY LICENSE NUMBER: 7. Name of Child(ren) Involved 3. LICENSEE’S NAME: 5. FACILITY ADDRESS: Birth date Mo/Day/Yr 8. Sex M/F 9. .

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