DAYCARE INCIDENT REPORT FORMINDIVIDUAL FILING REPORT

Full Name: [FULL NAME] Title/Role: [TITLE/ROLE]
Signature:                                                           Date: [MM/DD/YYYY]

INCIDENT DETAILSDate of Incident: [DATE OF INCIDENT]      Time: [TIME] ☐ AM ☐ PM

Facility Name: [FACILITY NAME] Location: [LOCATION]

Describe the Incident: [DESCRIBE THE INCIDENT]

PARTIES INVOLVEDFull Name: [FULL NAME] Age: [AGE] Phone: [PHONE] E-Mail: [EMAIL] Address: [ADDRESS]

INJURIESWas anyone injured? ☐ Yes ☐ No If yes, describe the injuries: [INJURY DESCRIPTION]

PARENT/GUARDIAN NOTIFICATIONWas the parent/guardian notified? ☐ Yes ☐ No

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

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

WITNESSESWere there witnesses to the incident? ☐ Yes ☐ No

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

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

POLICE/MEDICAL SERVICESPolice 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]

OFFICE USE ONLYReport received by: [FULL NAME]

Signature:                                                           Date: [DATE]

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