SAMPLE
ACCIDENT / INCIDENT REPORT
Facility/Home:
Child's Name: Age:
Date & Time of Accident/Incident:
Place of Accident/Incident:
Describe Accident/Incident:
Describe Nature of Injury:
Witness(es) to Accident/Incident:
What Action Was Taken?
Was Parent/Guardian Contacted? Time? How?
Other Persons Contacted:
Describe Medical Treatment/First Aid:
Signature of Staff Completing Form Date/Time
Signature of Director/Person in Charge Date/Time
Signature of Parent/Legal Guardian Date/Time
