The Incident Report Form

In the Guidelines for Early Childhood Development Services, issued by the Department of Social Development, this Incident Report Form was made available.

The Department requires that the form be completed in triplicate, one copy going to the parent, one copy to the child’s file and one copy to the accident file.

We list below the information to be filled in on this report form:

Name of the child:
Date of the incident:
Description of accident / injury / incident:
Where did it occur?
When did it occur?
Who witnessed the accident / injury / incident:
What injuries or symptoms resulted (describe part of the body)?
Was any blood present? How much blood?
Where was the blood?
What was done for the child (first aid treatment)?
Is any further medical attention required?
When was the parent notified?
When did the parent collect the child?
What advice was given to the parent?
Who was in charge when the incident occurred?
What measures are necessary to prevent such an incident in the future?
Signature and date: staff member
Signature and date: parent

First published in the Learning Years Vol 37 nr 1 – May 2012