DCYF 15-941 Child Care Incident Report Form PDF Details

The parent or guardian signs to acknowledge receiving a copy of this report.

Emergency response: Situation that required an emergency response from: Emergency services (911), Washington poison center, Department of Health

Risk situations: Situations that put children at risk, not limited to: Inappropriate sexual touching, Physical abuse, Neglect, Maltreatment, Exploitation, Other

Serious injury: Boxes for a serious injury to a child in care, from Severe bleeding and One or more fractured/broken bones to Injury resulting in overnight hospital stay

Contacts: Parent/Guardian Contacted and Licensor Contacted, each with date, time and In Person, Phone or E-mail

Signatures: Parent/Guardian Signature, Licensee/Staff Signature

Copies: Copies to: Parent, licensor, licensee

Question	Answer
Form Name	DCYF 15-941 Child Care Incident Report Form
Form Length	1 page
Fillable?	Yes
Fillable fields	46
Avg. time to fill out	8 min
Other names	DCYF 15-941, Child Care Incident Report, Child Care Injury/Incident Report
Edition	REV. 01/2023
Matches the agency's file	Yes, checked October 25, 2026
Official source	Form DCYF 15-941 (REV. 01/2023)

How to Fill Out Form DCYF 15-941

Form DCYF 15-941 at a glance

What it is: Child Care Injury/Incident Report: a provider must also complete this incident report, in addition to reporting incidents and injuries to the department by phone or email.

Where and when to file: A provider must submit this incident report within 24-hours. A provider must submit this incident report to DCYF.

A filled-in Form DCYF 15-941 example: a fall outdoors with 911 called

Form DCYF 15-941 example filled out, example: a fall outdoors with 911 called — A child care provider fills out Form 15-941 after an incident. A 4-year-old fell outdoors with severe bleeding, and emergency services (911) responded. The picture shows the filled boxes, and all its values are invented. The incident happened in the morning, so a.m. is ticked, and because the fillable form has no field for the hour, it is written by hand after printing. The parent was phoned at 11:05 AM and the licensor was emailed at 11:40 AM on the date of the incident, so In Person is left blank in both contact rows. Both signature dates are the date of the incident, and the signatures are signed on the printed copy because the fillable form has no field for them. The incident was an injury only, so nothing goes in Situations that may put children at risk, and Washington poison center and Department of Health stay empty.

How to fill out Form DCYF 15-941, box by box

Child's Name, Provider Name and Provider ID

Enter the Child's Name, the Provider Name and the Provider ID.

Child's Age, Date of Incident, Time of Incident and Incident Occurred

Enter the Child's Age and the Date of Incident, and check a.m. or p.m. for the Time of Incident.

Under Incident Occurred, check Indoors or Outdoors.

Staff present and treatment provided

List names of staff present and/or witnesses and the treatment provided to child while in care & by who.

Situation that required an emergency response from

Check All That Apply for the situation that required an emergency response from: Emergency services (911), Washington poison center or Department of Health.

Situations that may put children at risk

Check All That Apply for 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 or Other.

Serious injury to a child in care

Check All That Apply for serious injury to a child in care: Severe bleeding, One or more fractured/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 or Injury resulting in overnight hospital stay.

Brief description of the injury/incident

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

Parent/Guardian Contacted and Licensor Contacted

Under Parent/Guardian Contacted and under Licensor Contacted, enter the Date and Time and check In Person, Phone or E-mail.

Parent/Guardian Comments

Write the Parent/Guardian Comments.

Parent/Guardian Signature and Licensee/Staff Signature

Parent/Guardian Signature and Date: the Parent/Guardian signs and enters the Date.

Sign on the Licensee/Staff Signature line and enter the Date.

By signing this form, the signer acknowledges receiving a copy of this report.

Copies to: Parent, licensor, licensee.

Common questions about Form DCYF 15-941

Is there a deadline?

A provider must submit this incident report within 24-hours.

Where do I file it?

A provider must submit this incident report to DCYF.

Sources

[1] Form DCYF 15-941 (REV. 01/2023), Child Care Injury/Incident Report, Washington State Department of Children, Youth, and Families (the Official source link on this page).

DCYF 15-941: Child Care Injury/Incident Report