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
Bite
Bone Dislocation
Bone Fracture
Bruises
Burn
Chokes
Cut
Dental Injury
Eye Injury
Fall
Head Injury
Poisoning
Scrape
Sprain
Sting
Other
Provide a brief description of the injury.
Please provide details about the specific treatment the child received.
Signature