ACCIDENT / INCIDENT REPORT FOR FAMILY DAYCARE HOME

OR PRESCHOOL Date: _________________________________________________

Time: _________ A.M. P.M.

Child: ________________________________________________________________
Provider:______________________________________________________________

Location of accident/incident: How it occurred:   Action taken:


Parent was called?    YES NO Time called: _________ A.M. P.M.
 

Licensing Called/Reported to:_______________________________________________


Comments:  


DR, Nurse, Poison Control, etc. called?  YES or NO @: _______ A.M. P.M.

Comments:


The above accident/incident has been explained and discussed by both the provider and the parent/guardian. We agree and understand the accident/incident described above. This information has been reported accurately, to the best of our knowledge.

Signature of the Parent/Guardian:

 _______________________________________________________________________


Date____________________ _______________________________________________ 


Signature of the Provider:::

& _______________________________________________________________________

 

Date____________________________________________________________________