Child Care Incident Report Example 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.

QuestionAnswer
Form Name11 A R Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdaycare incident report example, childcare incident report example, how to write incident report in childcare, examples on how to fill an incident register in a day care centre

Form Preview Example

SAMPLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DCD - A/N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM 11A-r

 

 

 

 

 

 

INCIDENT REPORT FORM

 

 

 

 

 

 

 

 

Child Care Home

Child Care Center

County Name

 

 

 

 

 

 

 

 

 

Date/Time of Incident

 

 

 

Child's Name

 

 

 

 

 

 

Sex

 

Age

 

 

Witness to Incident

 

 

Parents Notified By

 

 

Time Notified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Piece of Equipment Involved:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Indoors:

Block

Furniture

Outdoors:

 

Bench

Climber Fence/Wall

Cubby

Door

Floor

Composite Play Structure

 

Deck

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

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Injury:

Dental Injury

Cut/Scrape

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 OfficeHospital/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

 

Date

Signature of Parent/Guardian

 

Date

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

REVISED 7/99

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