Preschool Incident Report Form

Child Information

First Name

Last Name

Date of Birth

Gender

Date and Time of Incident

Date of Incident

Time of Incident

Did parent/guardian get notified?

Yes

No

Time Notified

Parent/Guardian Name

Witness Name

Location of Incident

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

Choose a file or drop it here

Type of Incident

Provide a brief description of the injury.

Please provide details about the specific treatment the child received.

Reported by

Signature