Daycare Incident Report Form

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Daycare Incident Report Form

Last updated September 8th, 2025

A daycare incident report is used to keep a record of incidents that occur in a daycare facility. It includes the date and time of the incident, a description of what happened, a list of the persons involved, and whether emergency services were contacted. Keeping track of incidents and behaviors helps staff deal with recurring issues and enforce safety standards.

Incident Reporting Requirements

Licensed child care facilities are legally required to have policies and procedures for recording reportable incidents. Some states may have specific forms to use and reporting criteria that must be followed.

When an incident occurs, staff must take the following steps:

  1. Address immediate safety concerns.
  2. Notify the necessary authorities.
  3. Notify the child’s parent or legal guardian.
  4. Alert the appropriate licensing office.

Reportable Incidents

  • Medical emergencies
  • Aggressive acts against self or others
  • Unauthorized absences
  • Stolen or damaged property
  • Accidents and injuries
  • Suspected abuse or neglect

Sample

Download: PDF, MS Word, ODT

DAYCARE INCIDENT REPORT FORM
INCIDENT DETAILS
Date of Incident: [DATE OF INCIDENT]      Time: [TIME] ☐ AM ☐ PM

Facility Name: [FACILITY NAME]

Location: [LOCATION]

Describe the Incident: [DESCRIBE THE INCIDENT]

Follow-up action taken: [FOLLOW-UP ACTION TAKEN]

PARTIES INVOLVED

  1. Child Name: [CHILD NAME] Age: [AGE]  Parent/Guardian Name(s): [PARENT NAME(S)]  Phone Number: [PHONE]
  2. Child Name: [CHILD NAME] Age: [AGE]  Parent/Guardian Name(s): [PARENT NAME(S)]  Phone Number: [PHONE]
  3. Child Name: [CHILD NAME] Age: [AGE]  Parent/Guardian Name(s): [PARENT NAME(S)]  Phone Number: [PHONE]

INJURIES
Was anyone injured? ☐ Yes ☐ No

If yes, describe the injuries: [INJURY DESCRIPTION]

PARENT/GUARDIAN NOTIFICATION
Was the parent/guardian notified? ☐ Yes ☐ No

If yes, at what time? [TIME] ☐ AM ☐ PM

Name of person who contacted parent/guardian: [NAME OF PERSON]

Staff person in charge at time of incident: [NAME OF STAFF PERSON]

WITNESSES
Were there witnesses to the incident? ☐ Yes ☐ No

If yes, enter the witnesses’ names and contact info:

  1. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]
  2. Full Name: [FULL NAME] Phone: [PHONE] E-Mail: [EMAIL]

POLICE/MEDICAL SERVICES
Police Notified?☐ Yes ☐ No

If yes, was a report filed? ☐ Yes ☐ No

Was medical treatment provided? ☐ Yes ☐ No ☐ Refused

If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: [OTHER]

SIGNATURES
Staff Member Completing Form: [FULL NAME]

Staff Member Signature:                                                           Date: [MM/DD/YYYY]\

Director Signature:                                                           Date: [MM/DD/YYYY]

Parent/Guardian Signature:                                                           Date: [MM/DD/YYYY]