4.5: Incident Report Form
- Page ID
- 40923
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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]