Child Care Injury / Incident Report Provider Name Provider ID Name of Injured Child Age of Child Date of Incident Child s Gender Time of Incident am Male Female Called 911 Called Poison Control pm CHECK ALL THAT APPLY Type of Injury / - del 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Provider Name' and 'Provider ID' at the top of the form. This identifies your facility.
3. Fill in the 'Name of Injured Child' and their 'Age'. Ensure accuracy for proper documentation.
4. Record the 'Date of Incident' and 'Time of Incident', selecting AM or PM as appropriate.
5. Indicate the child's gender by checking either 'Male' or 'Female'.
6. Check if emergency services were called, such as 911 or Poison Control, based on the situation.
7. In the 'Type of Injury / Incident' section, check all applicable options to describe what occurred.
8. Provide details about any medical treatment given, including first aid or EMT involvement.
9. List names of staff present and provide a brief summary of the incident for clarity.
10. Finally, ensure that both parent/guardian and licensee/staff signatures are obtained along with dates.

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