4.5: Incident Report Form
- Page ID
- 40923
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\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)Incident Report Form
[Early Childhood Program Name]
Date of Incident:
Time of Incident: [HH:MM AM/PM]
Location of Incident: [Specify the location (e.g., classroom, playground)]
1. Personal Information
Child’s Name: [First and Last Name]
Age/Grade:
Parent/Guardian Name(s): [First and Last Name(s)]
Teacher/Caregiver Name:
2. Incident Details
Type of Incident:
☐ Injury
☐ Illness
☐ Behavioral Issue
☐ Other (Please specify): [______________]
Description of the Incident:
[Provide a brief and clear description of what happened, including any relevant context or preceding events.]
Witnesses (if any):
Name:
Name:
Name:
3. Nature of Injury (if applicable)
Body Part Affected (if applicable):
☐ Head
☐ Arm
☐ Leg
☐ Hand
☐ Other (Please specify): [______________]
Severity of Injury:
☐ Minor (e.g., bruise, small cut)
☐ Moderate (e.g., sprain, larger cut)
☐ Severe (e.g., fracture, concussion)
Was First Aid Administered?
☐ Yes
☐ No
If Yes, what treatment was given?
[Specify the type of treatment provided (e.g., ice pack, bandage, rest)]
Person Who Administered First Aid: [Name]
4. Immediate Actions Taken
Steps Taken During the Incident:
[Describe what was done immediately after the incident, including actions by staff members or others involved.]
Was Medical Attention Required?
☐ Yes
☐ No
If Yes, was the parent/guardian notified?**
☐ Yes
☐ No
Time of Notification:
5. Parent/Guardian Notification
Parent/Guardian Contacted:
☐ In-Person
☐ Phone
Name of Person Who Contacted Parent/Guardian: [Name]
Time of Contact: [HH:MM AM/PM]
Was the Parent/Guardian Informed About Further Action?
☐ Yes
☐ No
Additional Notes on Parent/Guardian Communication:
[Any additional details about the communication]
6. Follow-Up Required
Is Follow-Up Required?
☐ Yes
☐ No
If Yes, describe the necessary steps:
[Specify the follow-up actions required (e.g., additional monitoring, medical check-up)]
7. Staff Signature
Name of Staff Completing Report: [Name]
Signature: [Signature]
Date:
8. Administrative Review (Optional)
Reviewed by: [Administrator’s Name]
Title: [Title]
Date of Review:
Comments/Recommendations:
[Space for any additional comments or recommendations from the administrator]