Incident Report Sample - Free Download
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Sample Incident Report
Instructions
Complete this report under any of the following situations:
A. A child becomes ill or receives an injury that requires First Aid or medical treatment while
in your care;
B. A child receives a bump or blow to the head or other visible injury regardless of
treatment;
C. A child is transported by ambulance from your facility;
D. An unusual or unexpected incident occurs that jeopardizes the safety of a child, such as
a child left unattended, there is a vehicle accident (with or without injuries), or a child is
exposed to a threatening person or situation;
E. There is an allegation or reasonable suspicion of abuse of a child.
Important: Consult your state’s mandatory reporting requirements for further information
on abuse reporting; OR
F. As otherwise required by any state licensing or other authority, such as childcare or
daycare licensing. .
Date of Incident:
Time of Incident:
Name and Approximate Age of Child Involved (One Report per Child):
Contact Information for Child Involved:
Parent/Guardian:__________________________________________________________
Address:_________________________________________________________________
Telephone:__________________________ Email: ______________________________
Nature of Injury/Incident:
Location of Incident:
Description of Incident:
