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

Document and report significant Head Start child health and safety incidents to OHS with the right details, notifications, and follow-up in one place.

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Report Overview

Date of report (required)

Time of report (required)

Reporter name (required)

Reporter role (required)

Program or grantee name (required)

Center, home-based site, or location name (required)

Incident type (required)

Select all that apply. Additional fields will appear based on your selections.

Brief incident summary (required)

Describe what happened in plain language. Do not include unnecessary PII.

Child Information

Child identifier (required)

Use the child ID or internal identifier rather than full name when possible.

Child age

Enter age in years if needed for the report.

Child enrollment option (required)

Specify other enrollment option (required)

Was the parent or guardian notified? (required)

Time parent or guardian was notified

Incident Details

Date of incident (required)

Time of incident (required)

Incident location (required)

Specify other incident location (required)

Supervision status at the time of incident (required)

Environmental or contributing factors

Specify other contributing factor (required)

Health or Safety Impact

Did the child experience an injury or illness? (required)

Severity

Immediate medical response

Specify other medical response (required)

Was hospitalization required?

Immediate Response and Notifications

Internal notifications completed (required)

Specify other internal notification (required)

External notifications completed

Specify other external notification (required)

Is Office of Head Start notification required? (required)

Notification deadline

Enter the deadline if a report to OHS is required.

Follow-up, Consent, and Audit Trail

Follow-up actions taken or planned (required)

Corrective action owner

Target completion date

PII disclosure acknowledgement (required)

I understand this form collects only the minimum necessary PII for compliance reporting and follow-up, and the information will be used for audit trail, notification, and corrective action purposes.

Yes No N/A

Submitter signature (required)

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Email (required)

Your name (optional)

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