CTOEC Licensing Notification of Change for CCCs/GCCHs

Licensed youth camps are required to report any:
- Fatality that occurs at camp or results from camping activities
- Injury that occurs at camp or results from camping activities that result in a camper either:
  - Being admitted to a hospital
  - Diagnosed with a fracture, concussion, or second or third degree burn
You must report these incidents to the Office of Early Childhood (OEC) no later than the next business day.

To notify OEC of changes to your program, use this online form. (If you prefer, you can also download a PDF of this form and email (youthcamps@ct.gov) or fax (860-326-0556) it to us.
Program information (section 1 of 2)
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Youth camp name
License number
License number
Program email (where all OEC correspondence will be sent)
example@example.com
Phone
Please enter a valid phone number in this format 203-555-5555.Format: (000) 000-0000.
Facility address

Street Address

Street Address Line 2

CityState

Zip code

Tell us about the incident (section 2 of 2)
Date of incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Time of incident

Hour Minutes

AM/PM Option
Diagnosis (Select all that apply)
Full name of individual injured

First NameLast Name
Date of birth of individual injured

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Was the individual a camper or staff?
Parent/Guardian contacted

First NameLast Name
Relationship of parent/guardian
Phone Number of parent/guardian
Please enter a valid phone number.Format: (000) 000-0000.
Description of the incident, including circumstances that resulted in the incident/condition
Names of all staff members who witnessed the incident
Person(s) responding to incident and treatment provided
Other person(s) and agency(s) contacted
Ready to submit?

Make sure to review your responses first.
Your name (the person filling out this form)

First NameLast Name
Your title
Best phone number to reach you
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Program information (section 1 of 2)