INCIDENT REPORT FOR CHILD DAY CARE

􀃖 This form may be used to maintain a record of each child’s illnesses, accidents, injuries, signs of abuse, etc. 􀃖 Share a completed copy with parents.
Name of Child				Age
Details of Incident
Date	Type
Time	Place	(accident Illness Etc)
(Kitchen, playground, etc.)
Describe Incident :
Injuries :
Medical Services Provided:
Parent/Guardian/Other Notified
Name			Time	Date
Name			Time	Date
Witnesses
Name
Name
Staff				Date________

(Print Name)