Daycare Incident Report Form

Information you will need

• What’s the date of the incident?
• At what time did the incident occur?
• What's the facility's name?
• Where did the incident occur?
• What happened?
• What action was taken?
• What time of day did the incident occur?
• What’s the name of the child involved?
• What’s the child's age?
• What’s the name of the child's parent/guardian?
• What’s the parent/guardian’s phone number?
• What’s the name of the second child involved? (if applicable)
• What’s the second child's age?
• What’s the name of the second child's parent/guardian?
• What’s the second parent/guardian’s phone number?
• What’s the name of the third child involved? (if applicable)
• What’s the third child's age?
• What’s the name of the third child's parent/guardian?
• What’s the third parent/guardian’s phone number?
• What injuries were sustained? (if applicable)
• Was anyone injured?
• At what time did was the parent or guardian notified?
• Who contacted the parents or guardians?
• Who was in charge when the incident occurred?

…and 16 more fields in the PDF.

The form includes 4 signature lines, a witness section.