Occ Form 300 Reportable Child Incident Form

Maryland State Department of Education – Office of Child Care

REPORTABLE CHILD INCIDENT

COMARS 13A.15.03.05A Family Child Care Homes, 13A.16.03.06C Child Care Centers, 13A.17.03.06C Letters of Compliance Facilities, and 13A.18.03.06C Large Family

Child Care Homes require child care providers to notify or require that a staff member notify the Office of Child Care within 24 hours of (1) the death of a child if the child died

while at the facility; (2) the death of a child enrolled at the facility if the child died of a contagious disease; and (3) an injury to a child that occurs while the child is at the facility or

on a field trip which results in the child’s being treated by a medical professional or admitted to a hospital.

You may contact the office by phone or use this form for reporting purposes. If reporting by phone, please be prepared to give licensing staff all information requested on this

form. If submitting the completed form, be sure to fax or email it to your Regional Office of Child Care within 24 hours of the incident.

Name of Facility __________________________________________________ Address _______________________________City___________________ Zip Code_________

Date of Report ______________ Time of Report ____________ Name of Child ____________________________ DOB or Age of Child ____________

Male

Female

Name of Parent/Guardian ____________________________________ Address _______________________________Zip Code __________________ Phone ________________

Person Reporting _________________________ Relationship of Reporter to Facility __________________ Date of Incident _____________ Time of Incident ______________

Witnesses: Name____________________________________ Address _________________________________________ Zip Code ______________ Phone ________________

Name____________________________________ Address _________________________________________ Zip Code ______________ Phone ________________

Nature of Incident:

Death of child while in care

Death of child due to contagious disease (Name of Disease _________________________)

Child injury resulting in

treatment by medical professional

Injury resulting in admission to hospital (Name of Physician or Hospital _____________________________)

Injury resulting in death

Location:

Playground

Yard

Stairway

Bathroom

Kitchen

Playroom

Basement

Unapproved area (Where? _____________________________)

Off-site activity (Activity type and location ____________________________________________________________)

Unknown

Other ________________________

Cause of Injury:

Hit or cut by object

Fall from activity equipment (Object or Equipment Description________________________________________________________)

Fall from running or tripping

Bitten or scratched by other child

Burn

Hit or pushed by other child

Motor vehicle

Eating or choking

Insect sting or bite

Animal bite

Exposure to cold or heat

Other _________________________________________________________________________________________________

Details of Incident: _______________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________ ___________________

_____________________________________________________________________________________________________________________________ ___________________

________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________ ___________________

FOR OCC USE ONLY - Region ________

Licensing Staff Member Receiving Report: ___________________________ Regional Manager/Designee Informed: Date: __________________ Time: ________________

Notes: __________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________________ ___________________

________________________________________________________________________________________________________________________________________________

OCC Form 300 April 2016 (All previous formats obsolete)