Child Care Injury/Incident Report

Licensees name and address Name of child Describe circumstances of injury/incident

Date of incident

Time of incident

am pm

Where did the injury/incident occur? Play equipment, furniture or other items in ol ed?

Was first aid !i en? "f so, result#

Describe any other treatment !i en#

$es No Were there %itness&es'? "f yes, !i e name&s' (edical professional contacted? Was parent contacted? "f yes, !i e name) Time of contact) "f yes, !i e name) Time of contact)

*+#,#-#. "njury/"ncident /eport /e # *+/*+

0opies to) Parent, licensor and licensee

Was licensor contacted? Was 0hildrens 1dministration inta2e contacted? 1ny other contacts?

"f yes, !i e name) Time of contact) "f yes, !i e name) Time of contact) 333333333333333333333333333333333333333333 "f yes, !i e name) Time of contact)

(ar2 and describe area of injury)

Parent/!uardian comments Parent/!uardian si!nature Date Licensees si!nature Date

*+#,#-#. "njury/"ncident /eport /e # *+/*+

0opies to) Parent, licensor and licensee