11 A R Form PDF Details

11 A R Form is a versatile piece of software that can be used for a variety of purposes. Whether you need to create graphs and charts or organize your data, this software can help make the process easier. With its user-friendly interface and wide range of features, 11 A R Form is an essential tool for any business or individual.

This basic guide will help you establish the time it will require you to complete 11 a r form, the number of pages it has, and some additional unique details about the form.

Form Name11 A R Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesincident report childcare example, childcare behavior forms printable, child incident report example, how to write incident report in childcare

Form Preview Example










































FORM 11A-r
















Child Care Home

Child Care Center

County Name










Date/Time of Incident




Child's Name












Witness to Incident



Parents Notified By



Time Notified














































Piece of Equipment Involved:


















❏ Block

❏ Furniture



❏ Bench

❏ Climber ❏Fence/Wall

❏ Cubby

❏ Door

❏ Floor

❏ Composite Play Structure



❏ Swing

❏ Medication

❏ Toy

❏ Other Child

❏ Other Child


❏Sandbox ❏ Sidewalk





❏ Shelving

❏ Sink

❏ Steps

❏ Slide

❏ Surfacing

Merry-Go Round

❏ N/A

❏ Other:




❏ N/A

❏ Other Plygrnd Eqpmnt.










❏ Vehicle

❏ Toy



❏ Other:










Cause of Injury:

❏ Fall from Height

❏ Hit By or Bumped Into Object

❏ Human Bite

❏Sharp/Piercing Object


❏ Burn

❏ Splinter/Foreign Object

❏Pinched/Caught In















Type of Injury:

❏ Dental Injury


❏ Puncture

❏ Bite ❏ Bump/Bruise ❏ Splinter

❏ Burn

❏ Crush

❏ Fracture/Dislocation

❏ Sprain/Strain ❏ Other:


Body Part Injured:

❏ Head

❏ Eye

❏ Face

❏ Mouth

❏ Neck

❏ Arm ❏ Hand/Wrist/Finger ❏ Leg

❏ Abdomen/Trunk/Chest

❏ Knee ❏ Foot/Ankle

❏ Other



Where Child Received Treatment:

❏ Clinic

❏ Dentist

❏ Doctor’s Office❏ Hospital/ER

❏ Onsite By Health Professional

❏ Urgent Care

❏ Other




Description of How and Where Incident Occurred & First Aid Recd.:

Steps Taken to Prevent Reoccurrence

Signature of Staff Member



Signature of Parent/Guardian



Anytime a Child Receives Medical Treatment as a Result of an Incident Occurring at a Child Care

Center or Child Care Home this Report Must be Submitted Within 7 Calendar Days to your Child

Care Consultant {Rule 10 NCAC 3U .0802(d);10 NCAC 3U .1717(a)(3)(T)}

Original to Child’s File

Copy to Child Care Consultant

Copy to Parent/Guardian Enter into Incident Log

Date of Most Recent Playground Inspection __________________

Child Care Consultant’s Name


DCD-0582 3/97


How to Edit 11 A R Form Online for Free

Only a few things are quicker than filling out forms through our PDF editor. There isn't much you need to do to update the child care incident report form document - merely adopt these measures in the next order:

Step 1: Pick the button "Get Form Here".

Step 2: Once you've entered the child care incident report form editing page you'll be able to notice all of the functions you can carry out relating to your document in the top menu.

Enter the data required by the program to prepare the form.

examples on how to fill an incident register in a day care centre gaps to complete

Write the data in Dental Injury Burn, CutScrape, Puncture, Bite, Crush, FractureDislocation, SprainStrain, BumpBruise Other, Splinter, Body Part Injured, Head AbdomenTrunkChest, Eye, Face, Mouth, and Neck.

Filling in examples on how to fill an incident register in a day care centre step 2

The program will require for extra info with a purpose to effortlessly fill out the field Anytime a Child Receives Medical, Original to Childs File Copy to, Date of Most Recent Playground, Child Care Consultants Name, DCD, and REVISED.

step 3 to entering details in examples on how to fill an incident register in a day care centre

Step 3: In case you are done, choose the "Done" button to upload the PDF document.

Step 4: Have minimally a couple of copies of your file to keep clear of any kind of forthcoming troubles.

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