Appendix D: Sample Injury/Incident Report Form

Kelly McKown

Example Injury/Incident Report Form

Date Incident Occurred

 

Time Incident Occurred:
Child’s Name:

 

Age:
Adults that observed:

 

Where incident occurred: (describe location and any equipment)

 

Cause of injury: (description what happened beforehand and/or hazards involved)

 

Description of injury: (what type of injury and the part/s of body injured)

 

Description of first aid given:

 

Was medical treatment required?    No       Yes (please describe)

 

Follow-up plan for care of the child (if needed):

 

Corrective action needed to prevent reoccurrence:

 

Parent/Guardian that was contacted:

 

Time:
Notified by: Contact method:     Phone       In person

 

Staff Signature:

 

Date:
Parent/Guardian Signature:

 

Date:

License

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Appendix D: Sample Injury/Incident Report Form Copyright © by Kelly McKown is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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