CTOEC Licensing Notification of Change for CCCs/GCCHs

Licensed child care centers and group child care homes are required to report any:
- Injury of a child that occurs while the child is at the facility, or at a facility
  sponsored event, that results in a diagnosed fracture, diagnosed second or third degree burn, diagnosed concussion or the child’s admission to a hospital.
- Significant medication errors
- Death of a child enrolled at the facility, if the child died while at the facility, or at a facility sponsored event
You must report these incidents to the Office of Early Childhood (OEC) no later than the next business day.

Besides required reporting, you may also use this form to self report any other incident to the OEC. Just select the other option in section 2.

To notify OEC of any self reports on your program, use this online form.
Program information (section 1 of 2)
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child care center or group child care home 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)
What are you self reporting? (Select all that apply)

Other
Date of incident

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

Hour Minutes

AM/PM Option
Full name of child involved

First NameLast Name
Date of birth of child involved

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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
If no other agency was contacted, write none
If DCF was called, please upload DCF 136 form

Cancelof
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)