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