Skip to main content
Social Sci LibreTexts

19: Appendix D- Example Injury/Incident Report Form

  • Page ID
  • \( \newcommand{\vecs}[1]{\overset { \scriptstyle \rightharpoonup} {\mathbf{#1}} } \) \( \newcommand{\vecd}[1]{\overset{-\!-\!\rightharpoonup}{\vphantom{a}\smash {#1}}} \)\(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\) \(\newcommand{\id}{\mathrm{id}}\) \( \newcommand{\Span}{\mathrm{span}}\) \( \newcommand{\kernel}{\mathrm{null}\,}\) \( \newcommand{\range}{\mathrm{range}\,}\) \( \newcommand{\RealPart}{\mathrm{Re}}\) \( \newcommand{\ImaginaryPart}{\mathrm{Im}}\) \( \newcommand{\Argument}{\mathrm{Arg}}\) \( \newcommand{\norm}[1]{\| #1 \|}\) \( \newcommand{\inner}[2]{\langle #1, #2 \rangle}\) \( \newcommand{\Span}{\mathrm{span}}\)\(\newcommand{\AA}{\unicode[.8,0]{x212B}}\)

    Appendix D: Example Injury/Incident Report Form

    Date Incident Occurred

    Time Incident Occurred:

    Child’s Name:


    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:


    Notified by:

    Contact method: Phone In person

    Staff Signature:


    Parent/Guardian Signature:


    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.