Form 7239 Incident/illness Report
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1Texas Dept of Family
Form 7239
INCIDENT/ILLNESS REPORT
and Protective Services
July 2007
Fill in all appropriate areas. Use additional sheets as necessary.
Caregiver in Charge of Child
Operation Name
Operation ID #
Time Parent Notified
am
pm
Child’s Name
Date of Birth
Licensing notified? (if required)
Yes
No
Date/Time
Person’s name
Child’s Address
Date of Incident/Illness
Time of Incident/Illness
am
pm
Place of Incident
Parent’s Name
Parent’s Telephone
Date Parent Notified
Did the child see his/her doctor?
Was medical
Was First Aid Provided?
Yes
No
Was EMS called?
Yes
No
attention required?
Yes
No
What was done?
Time called
am
pm
Time responded
am
pm
Yes
No
If so, fill out information below:
Child’s Doctor
Doctor’s Address
Doctor’s Phone #
Doctor called
yes (time
)
no
Doctor’s Diagnosis or Instructions
Date/Time Consulted
am
pm
A. Details of Incident That Caused Injury or Placed Child at Risk:
Describe injury or risk in which child was placed:
Where and how did the incident/injury occur?
Staff who witnessed the incident/injury.
Other staff who were present at the time of the incident/injury.
B. Details of On-set of Illness While in Care
Type of Illness
Does the illness require exclusion from care?
Yes
No
If communicable: other parents notified?
Yes
No
Health Dept. notified?
Yes
No
Method used:
Date
Temperature of Child
Medication given
I verify that the above information is a true and accurate account of the incident/injury that occurred concerning this child.
_________________________________________________________
____________________________________________
Signature of Director/Person in Charge
Date Signed
I verify that the director/person in charge appropriately relayed the information concerning the incident/injury concerning my child. I have received a
copy of this report.
_________________________________________________________
____________________________________________
Signature of Parent
Date Signed
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