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