Preschool Incident Report Form

First Name

Last Name

Date of Birth

Gender

Date of Incident

Time of Incident

Did parent/guardian get notified?

Time Notified

Parent/Guardian Name

Witness Name

Location of Incident: Be very specific (e.g., "Playground - near the swings," "Classroom - art center," "Bathroom - girls' restroom"). A simple map or diagram could be helpful for larger centers.

Upload the map or diagram

Type of Injury

Provide a brief description of the injury.

Please provide details about the specific treatment the child received.

Signature