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Run: Childcare Incident and Injury Report and Parent Notification Form

This childcare incident and injury report records what happened, what care was given, and how parents or guardians were notified. Use it to create a clear fo...

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Submission Notice

Date of report (required)

The date this report is completed.

Time of report (required)

The time this report is completed.

Staff member completing the report (required)

Enter the name of the staff member completing this form.

What is being reported? (required)

Date of incident (required)

The date the incident occurred.

Time of incident (required)

The approximate time the incident occurred.

Child Information

Child initials (required)

Use initials if your organization allows it for internal reporting. If full name is required by policy, use only the minimum necessary.

Child age group (required)

Room or group (required)

The classroom, room, or care group where the child was assigned.

Staff present at the time

List staff initials or role titles only if needed for the audit trail.

Incident Details

Location of incident (required)

Description of incident (required)

Describe what happened, what the child was doing, and any contributing factors observed.

Were there witnesses? (required)

Witness details

Provide witness names or initials and a brief summary of what they observed.

If other, describe the incident type

Injury or Illness Details

Did an injury occur? (required)

Body part affected

Severity

Symptoms or signs observed

Describe other symptoms

First Aid and Emergency Response

Was first aid given? (required)

First aid provided

Were emergency services called? (required)

Emergency response details

Include the time called, agency contacted, and where the child was transported if applicable.

Was medical follow-up recommended? (required)

Parent or Guardian Notification

Was the parent or guardian notified? (required)

Date notified

Time notified

Notification method

Notified by

Staff member who contacted the parent or guardian.

Parent or guardian response

Summarize any instructions, concerns, or follow-up requests from the parent or guardian.

Follow-up and Review

Follow-up actions

Describe any monitoring, classroom changes, parent follow-up, or corrective actions taken.

Supervisor reviewed this report (required)

Review date

Retention note

Retain this report according to your childcare licensing, record retention, and internal audit policy.

Get your results

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Email (required)

Your name (optional)

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