Appendix D: Sample Injury/Incident Report Form
Example Injury/Incident Report Form
| Date Incident Occurred
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Time Incident Occurred: |
| Child’s Name:
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Age: |
| Adults that observed:
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|
| Where incident occurred: (describe location and any equipment)
|
|
| Cause of injury: (description what happened beforehand and/or hazards involved)
|
|
| Description of injury: (what type of injury and the part/s of body injured)
|
|
| Description of first aid given:
|
|
| Was medical treatment required? No Yes (please describe)
|
|
| Follow-up plan for care of the child (if needed):
|
|
| Corrective action needed to prevent reoccurrence:
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|
| Parent/Guardian that was contacted:
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Time: |
| Notified by: | Contact method: Phone In person
|
| Staff Signature:
|
Date: |
| Parent/Guardian Signature:
|
Date: |
