Incident Report Date Time: Reporting Staff Mei Child’s Name: Time of Parent Notification; Staff Member's Report: Supervisor Notified: Supervisor's Note: Follow Up Required?: YES NO Parent's Explanation:Accident Injury Report Form Name of injured child Parents’ name Parents’ address Phone number Date when injury occurred Time when injury occurred 1. Where injury occurred (ex.: room 260 loft, sandbox etc.) 2. Description of how injury occurred 3. Name of consumer product involved (if any) 4, Description of injury/condition of child 5. Action taken by staff (first aid) and results 6. Other pertinent information 7. What corrective measures could be taken to eliminate such accidents in the future? 7. Name of individual(s) involved in supervision at time of accident. Witness: Witness: Parent Notification ‘Was the parentlegal guardian specifically advised of injury? | By whom? Time of parent notification ‘Was the parent/legal guardian advised to obtain medical attention? Signature of parent/legal guardian Signature of person completing this form: Date of completion of this form