Appendix C:  EEC Injury Report Form

Injury Report Form

Program_______________________________________ EEC Program #____________________

Address_______________________________________ Telephone #______________________

Administrator/Site Coordinator__________________________________

Section One: to be completed for each injury occurring at the center

Child’s Name_____________________________________ Date of Birth___________________

Date of injury____________________________ Time of injury__________________

Description of injury__________________________________________________________________________

___________________________________________________________________________________________

How did injury occur?_________________________________________________________________________

___________________________________________________________________________________________

If applicable, description of equipment involved (location, condition)___________________________________

___________________________________________________________________________________________

Where did injury occur? (Playground, classroom A)__________________________________________________

What group was the child in when injury occurred? _________________________________________________

Number of children in the group?___________

Names & qualifications of staff supervising the group when injury occurred?_____________________________

___________________________________________________________________________________________

Who witnessed/observed injury?________________________________________________________________

Staff present at time of injury?__________________________________________________________________

Who administered first aid?____________________________________________________________________

What first aid was administered? _______________________________________________________________

__________________________________________________________________________________________

Was parent/guardian notified? Yes____ No____ How?_______________ Time?________________

Was anyone else notified? Who?_______________ How?______________ Time?________________

Description of any corrective action taken to prevent similar occurrence ________________________________

___________________________________________________________________________________________

Section Two: to be completed in addition to Section One when medical treatment is received

Was 911 called? Yes____ No____

Was child transported for medical attention? Yes____ No____

Where?______________________________________ By Whom?_____________________________________

What treatment was provided? (be specific) _______________________________________________________

___________________________________________________________________________________________

Diagnosis of child? ___________________________________________________________________________

Did child return? Yes_____ No___ When?_________________________________________________________

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE:

Signature of person who completed form_______________________________ Date_________________

Signature of administrator who reviewed form___________________________ Date_________________

Signature of Parent/Guardian_________________________________________ Date_________________

Submitted to EEC within 5 business days if child receives medical treatment: Placed in child’s file______ Entered in record of incidents______

Injury report______ Copy provided to parents_____ Copy of First aid cards for staff involved_____ If applicable, supporting documentation________

EEC USE: Licensor Review: Initials _____________ Date____________

License

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