Childcare Accident Report
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1Childcare Accident Report
Name of Child: ________________________________________________________________________
Date of Accident: ______________________________ Time of Accident: _________________________
Nature of Injury: _______________________________________________________________________
Describe the Accident: __________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Caregiver Name: _______________________________________________________________________
First Aid Given: ________________________________________________________________________
_____________________________________________________________________________________
Was the parent contacted?
Y
N
How? ______________________________________
Which parent was contacted? ____________________________________________________________
Who contacted the parent? ______________________________________________________________
What time were they contacted? __________________________________________________________
Additional Contacts or Actions: ___________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Additional Notes: ______________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Provider Signature: _______________________________________ Date: ________________________
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Parent category: Business