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Run: Head Start Child Health and Safety Incident Report (OHS)

Document a reportable child health or safety incident for Head Start and capture the details OHS expects in one place. This template helps staff record what ...

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Report Overview

Date of incident (required)

Time of incident (required)

Reported by (required)

Reporter role (required)

Incident location (required)

Is this believed to be a significant child health or safety incident reportable to OHS? (required)

Why is this being reported? (required)

Brief summary of what happened (required)

Describe the event factually and concisely. Avoid speculation.

Child Information

Child initials (required)

Use initials if your program’s reporting process allows it; otherwise enter the child’s name per local policy.

Child age (required)

Program option (required)

Classroom, home visit group, or service setting

Was the child in program care or supervision when the incident occurred? (required)

Additional child details

Only include details necessary for the incident record and follow-up.

Incident Details

Incident type (required)

Did an injury occur? (required)

Describe the injury (required)

Was medical attention needed? (required)

How long was the child missing? (required)

Enter the estimated number of minutes.

Describe the hazard or unsafe condition (required)

Contributing factors

Notifications and Response

Immediate actions taken (required)

Was the parent or guardian notified? (required)

Time parent or guardian was notified

External notifications made

Notification details

Include who was contacted, when, and by whom. Do not include unnecessary PII.

Anonymous submission requested for internal follow-up?

Use only if your internal process allows anonymous intake for follow-up concerns. This does not remove required compliance reporting obligations.

Yes No N/A

Corrective Actions and Follow-up

Corrective actions taken or planned (required)

Was a policy, procedure, or supervision plan updated? (required)

Follow-up owner

Follow-up due date

Supporting documentation

Attach only documents needed for the audit trail, such as witness statements, photos, or notification logs.

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Email (required)

Your name (optional)

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