Incident Report Form

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Reference: American Academy of Pediatrics, Pennsylvania Chapter. 2002. Model child care health policies. 4th ed. Washington, DC: National Association for the Education of
Young Children, 1997.
This form was developed for Model Child Care Health Policies, 2002, by the Early Childhood Education Linkage System (ECELS), a program funded by the Pennsylvania
Depts. of Health & Public Welfare and contractually administered by the PA Chapter, American Academy of Pediatrics.
Caring for Our Children: National Health and Safety Performance Standards
CC
Incident Report Form
Fill in all blanks and boxes that apply.
Name of Program: ____________________________________________ Phone: ___________________________
Address of Facility: _____________________________________________________________________________
Child’s Name: ______________________________ Sex:
M
F Birthdate: ___/___/___ Incident Date: ___/___/___
Time of Incident: ___:___
am
pm Witnesses:______________________________________________________
Name of Legal Guardian/Parent Notified: ______________ Notified by: ______________ Time Notified: ___:___
am
pm
EMS (911) or other medical professional
Not notified
Notified
Time Notified: ___:___
am
pm
Location where incident occurred:
Playground
Classroom
Bathroom
Hall
Kitchen
Doorway
Gym
Office
Dining Room
Stairway
Unknown
Other (specify)___________
Equipment / Product involved:
Climber
Slide
Swing
Playground Surface
Sandbox
Trike/Bike
Handtoy (specify): _________________________________________________________
Other Equipment (specify):_____________________________________________________________
Cause of Injury (describe): _______________________________________________________________________
Fall to surface; Estimated height of fall ___feet; Type of surface: ________________________________
Fall from running or tripping
Bitten by child
Motor vehicle
Hit or pushed by child
Injured by object
Eating or choking
Insect sting/bite
Animal bite
Exposure to cold
Other (specify):________________________________________________________________
Parts of body injured:
Eye
Ear
Nose
Mouth
Tooth
Part of face
Part of head
Neck
Arm/Wrist/Hand
Leg/Ankle/Foot
Trunk
Other (specify): _____________
First aid given at the facility (e.g. comfort, pressure, elevation, cold pack, washing, bandage): _____________________
_________________________________________________________________
Treatment provided by: __________________________________________________________________________
No doctor’s or dentist’s treatment required
Treated as an outpatient (e.g. office or emergency room)
Hospitalized (overnight) # of days: _________
Number of days of limited activity from this incident: _________ Follow-up plan for care of the child: _____________
_________________________________________________________________
Corrective action needed to prevent reoccurrence:
______________________________________________________
Name of Official/Agency notified: __________________________________________________________________
Signature of Staff Member: ______________________________________________ Date: ____________________
Signature of Legal Guardian/Parent:______________________________________ Date: _____________________
Reference: American Academy of Pediatrics, Pennsylvania Chapter. 2002. Model child care health policies. 4th ed. Washhington, DC: national Association for the
Education of Young Children.
This form was developed for Model Child Care Health Policies, 2002, by the Early Chhildhood Education Linkage System (ECELS), a program funded by the
Pennsylvania Depts. of Health & Public Welfare and contractually administered by the PA Chapter, American Academy of Pediatrics.
Appendix CC

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