Appendix D: Example Injury/Incident Report Form
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Date Incident Occurred |
Time Incident Occurred: |
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Child’s Name: |
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: |
Time: |
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Notified by: |
Contact method: Phone In person |
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Staff Signature: |
Date: |
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Parent/Guardian Signature: |
Date: |