ACCIDENT/INCIDENT REPORT  

Name of Center:_________________________________________

Child's Name: ________________________    Date Accident Occured:____________

Time Accident Occured: ___________ am_____   or   pm_____

Supervising Teacher: _________________   Accident Location: ____________________

Injury Type: ________________________________

Describe How Incident/Accident Occured:__________________________________________
___________________________________________________________________________
___________________________________________________________________________

Describe First Aid/Treatment Given(if any):_________________________________________
___________________________________________________________________________
___________________________________________________________________________

Parent Signature________________________   Supervisor Signature__________________________

Copyrightę 2004 The Daycare Resource Connection. All Rights Reserved.


  ACCIDENT/INCIDENT REPORT  

Name of Center:_________________________________________

Child's Name: ________________________    Date Accident Occured:____________

Time Accident Occured: ___________ am_____   or   pm_____

Supervising Teacher: _________________   Accident Location: ____________________

Injury Type: ________________________________

Describe How Incident/Accident Occured:__________________________________________
___________________________________________________________________________
___________________________________________________________________________

Describe First Aid/Treatment Given(if any):_________________________________________
___________________________________________________________________________
___________________________________________________________________________

Parent Signature________________________   Supervisor Signature__________________________

Copyrightę 2004 The Daycare Resource Connection. All Rights Reserved.