Child Care Incident Report PDF Details

In the world of child care, ensuring the safety and well-being of children is paramount. When the unexpected happens, such as an injury or incident, clear and prompt communication becomes indispensable. The Child Care Incident Report form plays a critical role in this communication chain. By meticulously documenting the who, what, when, and where of any incident or injury, this form acts as a vital tool for child care providers, helping them to not only record the details of the event but to also fulfill their regulatory obligations. It requires the provider to include essential information such as the child’s name, age, the date and time of the incident, whether it occurred indoors or outdoors, and the names of any staff or witnesses present. Treatment details provided to the child and the involvement of emergency services, if any, are also to be recorded. Moreover, the form addresses situations of a severe nature that might involve emergency responses, such as poisoning or severe injuries, ensuring that such serious incidents are flagged appropriately. Submitting this form to the Department of Children, Youth, and Families within 24 hours highlights the urgency and significance of swift action and thorough documentation in promoting the safety and welfare of children in care settings. By so doing, it not only serves as a record for accountability but also as a tool for parents and guardians to be informed and involved in the aftermath of an incident, working towards a transparent and trusting relationship between parents and child care providers.

QuestionAnswer
Form NameChild Care Incident Report
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdaycare incident report form, child care incident report form, child care injury incident report, incident report daycare template

Form Preview Example

Child Care Injury/Incident Report

Child’s Name:

In addition to reporting to the department by phone or email about the following incidents and injuries,

a provider must also complete this incident report and submit it to DCYF within 24-hours.

Provider Name

 

 

Provider ID

 

 

 

 

 

 

Child’s Age

Date of Incident

Time of Incident

Incident Occurred

 

 

 

a.m. p.m.

Indoors

Outdoors

 

 

 

 

List names of staff present and/or witnesses:

Treatment provided to child while in care & by who:

 

 

 

 

 

Check All That Apply

Situation that required an emergency response from:

Emergency services (911)

Washington poison center

Department of Health

110-300-0475(2)(b)/110-301-0475(2)(b)

110-300-0475(2)(c)/110-301-0475(2)(c)

110-300-0475(2)(d)/110-301-0475(2)(d)

Situations that occur while children are in care that may put children at risk including, but not limited to:

Inappropriate sexual touching

Physical abuse

Neglect

Maltreatment

Exploitation

Other

 

 

 

 

Serious injury to a child in care:

Severe bleeding

One or more broken bones

Choking or serious unexpected breathing problems

Severe neck/head injury

Sudden unconsciousness

Dangerous chemicals in eyes, on skin, or ingested

Near drowning

Shock or acute confused state

Severe burn requiring professional medical care

Poisoning

Overdose of chemical substance

Injury resulting in overnight hospital stay

Please give a brief description of the injury/incident, including where it occurred.

 

Parent/Guardian Contacted

 

 

 

Licensor Contacted

 

 

Date:

Time:

In Person

Phone

E-mail

Date:

Time:

In Person

Phone

E-mail

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Comments:

Parent/Guardian Signature

Date

By signing this form, I acknowledge that I received a copy of this report.

Licensee/Staff Signature

Date

CHILD CARE INJURY/INCIDENT REPORT

Copiesto: Parent, licensor, licensee

DCYF 15-941 (REV. 6/2021) EXT

 

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The next sections will make up the PDF file that you will be creating:

step 1 to filling in daycare accident report

Type in the required details in the section Severe neckhead injury, Sudden unconsciousness, Dangerous chemicals in eyes on, Near drowning, Shock or acute confused state, Severe burn requiring professional, Poisoning, Overdose of chemical substance, Injury resulting in overnight, Please give a brief description of, ParentGuardian Contacted, Licensor Contacted, Date Time, In Person, and Phone.

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