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19: Appendix D- Example Injury/Incident Report Form

  • Page ID
    69648
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    Appendix D: Example Injury/Incident Report Form

    Date Incident Occurred

    Time Incident Occurred:

    Child’s Name:

    Age:

    Adults that observed:

    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:

    Parent/Guardian that was contacted:

    Time:

    Notified by:

    Contact method: Phone In person

    Staff Signature:

    Date:

    Parent/Guardian Signature:

    Date:


    This page titled 19: Appendix D- Example Injury/Incident Report Form is shared under a CC BY license and was authored, remixed, and/or curated by Jennifer Paris.