Eec Incident Action Plan (Page 2 of 2) in pdf

How did the child respond to the educator’s intervention? ___________________________________________________

__________________________________________________________________________________________________

What was the outcome of the incident that occurred? Any injuries to this child or other children? Any property damage?

Was 911 or other emergency personnel contacted?

__________________________________________________________________________________________________

Who contacted the parent/guardian? ____________________________________________________________________

How? ____________________________________ Date/Time parent/guardian notified? __________________________

Was a meeting scheduled with the parent to discuss the incident?

Yes or No

(circle one)

Date of meeting: ____________________________Time of meeting: _________________________________________

Who was present at the meeting? Who was representing the program? Who was representing the family?

__________________________________________________________________________________________________

With parental consultation and authorization, has a referral been made on behalf of the child? By whom?

__________________________________________________________________________________________________

In cooperation with the parents/guardian, what plan was developed to address any concerns?

__________________________________________________________________________________________________

Signature of Staff

Date

__________________________________________________________________________________________________

Signature of Parent/Guardian (optional)

Date

_____Administrative Review

_____Placed in Child’s file

_____Entered in Central Log or File

**This form should be completed by all staff involved in or observing the incident and reviewed by the program administrator

Page 2 of 2

SG/LG/SAIncidentPlan20100920

Eec Incident Action Plan Page 2