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INCIDENT FORM DATE: FOSTER CARE PROVIDER: ADDRESS: TELEPHONE NUMBER: DATE OF INCIDENT: CHILD(REN) INVOLVED: WHERE DID INCIDENT HAPPEN: WHO ELSE WAS THERE: WHAT HAPPENED: MEDICAL TREATMENT REQUIRED: YES NO IF YES, LIST DOCTOR AND/OR HOSPITAL, IF KNOWN: CHILD’S WORKER NOTIFIED? YES NO WORKER’S NAME: Signature of Provider Date * Please return this form to Clay County Licensor within 24 hours of injury. CCSS 8/2017