Childcare Committee Accident Incident Report Form printable pdf download

Accident / Incident Report Form

Child’s Name: _________________________________________________Date of birth:____ /____/____

Address: _______________________________________________________________________________

_______________________________________________________________________________________

Details of Accident/Incident

Date of accident/incident: _____________________________ Time of accident/incident: ___________

Description of accident/incident: (nature of any injury/illness etc.)

_______________________________________________________________________________________

Who was present at time of accident/incident? ______________________________________________

_______________________________________________________________________________________

Witnesses of accident/incident: ___________________________________________________________

_______________________________________________________________________________________

Actions taken and by whom: ______________________________________________________________

_______________________________________________________________________________________

Parents/Guardian contacted

Yes

GP contacted

Yes

Ambulance / Hospital contacted

Yes

Comments/ any follow on action required:

_________________________________________________

_______________________________________________________________________________________

Childminders Signature:________________________________________________ Date:____ /____/____

Parent/ Guardian Signature: ____________________________________________ Date:____ /____/____

These forms should be easily accessible and kept in book format.

These forms have been developed by the City and County Childcare Committees of Dublin City,

Dún Laoghaire Rathdown, Fingal and South Dublin.

Funded by the Irish Government under the National Development Plan 2007-2013

Childcare Committee Accident Incident Report Form