Child Care Incident Report Form PDF Details

A child care incident report form is a document that parents fill out and submit to their employer when they observe any incidents of misconduct by the staff of the daycare center. These reports can be used by employers to keep track of how often certain types of discipline are needed in order to maintain a safe environment for children, as well as help them identify potential problems with particular members or specific management styles. It also provides an opportunity for employees who might not otherwise feel comfortable speaking up about an issue at work to anonymously raise concerns without fear of reprisal from coworkers or supervisors.

We've compiled some technical information about the child care incident report form. There, you'll discover the information about the form you want to fill in, such as the approximate time required to fill it out and other details.

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

Form Preview Example

DEPARTMENT OF CHILDREN AND FAMILIES

dcf.wisconsin.gov

Division of Early Care and Education

Incident Report – Regulated Child Care Centers

Use of form: This form is voluntary; however, completion of this form meets the requirements of DCF 202.08(1)(c)1., 250.04(3)(a), 251.04(3)(a) and 252.41(2)(a) of the Wisconsin Administrative Codes. Failure to comply may result in an enforcement action or issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wis. Stats.].

Instructions: The licensee / certified provider shall report any death of a child in care, or any incident or accident that occurs while the child is in care that results in an injury that requires professional medical treatment. Licensee shall notify the department within 48 hours of becoming aware of the medical treatment. Certified provider shall notify the certifying agency as soon as possible but no later than the agency’s next working day. Submit a completed form to the regional licensing / certification office. Retain a copy in the child’s record.

CHILD CARE CENTER INFORMATION

Name – Child Care Center / Certified Provider

Facility / Provider Number

Telephone Number

Address – Child Care Center / Certified Provider (Street, City, State, Zip Code)

CHILD AND PARENT INFORMATION

Name – Child

 

 

Birthdate (mm/dd/yyyy)

 

 

 

 

 

 

 

Name – Parent(s) / Guardian(s)

 

 

 

 

 

 

 

 

 

Telephone Number – Child's Home

Telephone Number – Parent / Guardian – Home

Telephone Number – Parent / Guardian – Work

 

 

 

 

 

 

INCIDENT INFORMATION

 

 

 

 

 

Incident Location

 

 

Incident Date

Incident Time

 

 

 

 

 

A.M.

P.M.

 

 

 

 

 

 

Names – Adult Witnesses

 

 

 

 

 

 

 

 

 

 

 

Incident Description

 

 

 

 

 

 

 

 

 

 

 

Nature and Extent of Injury

 

 

 

 

 

 

 

 

 

If a Toy was Involved in the Incident – Name and Type

 

 

 

 

 

 

Activity in Which Child was Engaged When Incident Occurred – Describe

 

 

 

 

 

 

How Parent was Notified of Incident – Describe (Include date and time)

 

 

 

 

 

 

Action Taken (e.g., first aid, clean up, decontamination, etc.)

 

 

 

 

 

 

 

 

MEDICAL INFORMATION

 

 

 

 

 

Name – Hospital or Clinic

 

Name – Physician

 

 

 

 

 

 

 

 

Address – Hospital or Clinic (Street, City, State, Zip Code)

Medical Treatment Provided by Medical Professional – Describe

SIGNATURE – Child Care Center Representative / Certified Child Care Provider

Date Signed

FOR DEPARTMENT USE ONLY

Yes

No

Is additional investigation required? If "Yes" attach written report.

Date Reviewed

 

SIGNATURE – Licensing Specialist / Certification Worker

 

 

 

 

DCF-F-CFS0055-E (R. 01/2013)

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