Step 1: Click "Get Form Here" to open the 11 A R Form in FormsPal's editor.
Step 2: Use the top toolbar to add text, check boxes, and signatures to the required fields.
Enter the data required by the program to prepare the form.
Select the correct injury type: Dental Injury, Burn, Cut/Scrape, Puncture, Bite, Crush, Fracture/Dislocation, Sprain/Strain, Bump/Bruise, Other, or Splinter. Then choose the body part that was injured.
Enter additional details: date medical care was sought, child's file copy placement, date of last playground inspection, and the Child Care Consultant's name.
Step 3: Click "Done" to save and download the completed PDF.
Step 4: Keep at least two copies for your records.
Key Fields on the 11-A-R Incident Report
Complete each of these fields for a valid 11-A-R submission:
- Child's name, sex, and age
- County, date, and time of the incident
- Exact location where the incident occurred
- Witness names (staff or bystanders present)
- Parent notification time and method
- Equipment involved (indoor or outdoor)
- Injury type and body part affected
- Treatment location (on-site first aid or medical facility)
- Steps taken to prevent a repeat incident
- Staff and parent signatures with dates
Tips for Accurate Incident Reporting
Write the incident description right away, while details are clear. Use specific location terms (example: "top rung of the north slide") rather than just "playground." Submit the form to your Child Care Consultant within seven days if the child received medical care.
Conduct a playground safety inspection after any equipment-related incident and attach findings to the report. File the original in the child's permanent record and send a copy to the consultant. For a general incident template covering other situations, see the child care incident report form. New families can use the daycare registration form to complete enrollment.
