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ACCIDENT REPORT
Child's Name:______________________________________ Date Accident occured: ____ Time Accident occured:________ What was injured and where? __________________________ What was child doing?_________________________________ __________________________________________________ First aid :___________________________________________ Additional Information_________________________________ ____________________________________________________________________________________________________
Was parent contacted? _____ Which parent? _______________ Who contacted parent?________________________________ Time parent was contacted?________ Did parent have any special requests as to any action taken?__________________________________________________
__________________________________________________ Provider Signature Date
__________________________________________________ Parent Signature Date
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