Child Care Incident Report PDF Details

Effective and immediate communication is essential in situations like injuries or accidents. The accident report form for preschool is critical in this communication chain. By documenting all details of any incident or injury, this form helps child care providers to record the event accurately and fulfill their regulatory obligations.

This childcare incident report template includes information on the child involved, the provider, and specifics about the incident, such as the date, time, and location. Types of incidents covered are:

- Emergency responses from services like 911 or poison centers.

- Risks like neglect, physical abuse, or maltreatment.

- Severe injuries requiring medical attention or hospitalization.

Our daycare incident report example also lists witnesses, describes any immediate treatment, and notes when parents and licensors were informed. Signatures from the parent/guardian and licensee confirm acknowledgment and receipt of the document, ensuring all parties are informed.

The child incident report template can be helpful for healthcare professionals or legal advisors when additional medical care is required, or legal issues arise.

QuestionAnswer
Form Name Child Care Incident Report
Form Length 1 pages
Fillable? Yes
Fillable fields 17
Avg. time to fill out 8 min
Other names daycare 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

 

How to Edit Child Care Incident Report Online for Free

This guide provides step-by-step instructions to ensure the childcare accident report form is completed accurately.

1. Child and Provider Details

Start filling out this daycare accident report form by entering the child's name, age, provider name, and ID.

2. Incident Timing and Location

Specify the date and time when the incident occurred. Indicate whether the incident took place indoors or outdoors.

3. Describe the Incident

Provide a detailed description of the incident. Include information about what the child was doing at the time and how the incident happened. Be factual and concise, avoiding opinions or assumptions about the cause.

step 1 to filling in daycare accident report

4. List Witnesses

Note the names of any staff members or other witnesses present during the incident. This is important for follow-up and if further investigation is necessary.

5. Treatment Provided

Document any immediate medical treatment given to the child at the scene and name the person who administered the treatment.

Filling in daycare accident report step 2

6. Relevant Situations

Indicate if the situation required an emergency response or if it involved risks like neglect or physical abuse. This section helps categorize the severity and type of incident for regulatory purposes.

7. Notify Parent/Guardian and Licensor

Record the date and method of communication used to inform the child's parent or guardian and the licensor about the incident.

8. Comments and Signatures

Gather any additional comments from the parent or guardian regarding the incident and their understanding. Obtain signatures from both the parent or guardian and a staff member or licensee to acknowledge that all parties are informed and the report is complete.

Watch Child Care Incident Report Video Instruction

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