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.
| Question | Answer |
|---|---|
| Form Name | Child Care Incident Report Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | daycare incident report template, preschool incident report sample, daycare incident report form, preschool incident report template |
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 |
|
|
|
|
|