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__________________________ Copyright© 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__________________________ Copyright© 2004 The Daycare Resource Connection. All Rights Reserved.