Childcare Accident Report

Name of Child: ________________________________________________________________________

Date of Accident: ______________________________ Time of Accident: _________________________

Nature of Injury: _______________________________________________________________________

Describe the Accident: __________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Caregiver Name: _______________________________________________________________________

First Aid Given: ________________________________________________________________________

_____________________________________________________________________________________

Was the parent contacted? Y N How? ______________________________________

Which parent was contacted? ____________________________________________________________

Who contacted the parent? ______________________________________________________________

What time were they contacted? __________________________________________________________

Additional Contacts or Actions: ___________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Additional Notes: ______________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Provider Signature: _______________________________________ Date: ________________________