Fall to surface; estimate height of fall _______________; type of surface ______________________; depth of surface ___________________
Fall from running or tripping
Injured by object
Insect sting/bite
Other (specify): ___________________________________________________________________
Hit or pushed
Slipped
Eating or choking
Pinched by:
Bitten by:
Motor Vehicle
Cut
Unknown/not witnessed
equipment
person
human
animal
Describe Incident
Type of Injury (ies): (check all that apply)
Bite; was skin broken?
Crushing injury
Sliver
Other (specify): ___________________________________________________________________
Loss of consciousness
Sting
Burn
Skinned/Scrape
Broken bone
Bump
Nose Bleed
Puncture
Scratch
Sprain/Strain
Bruise or swelling
Yes
No
Location of Bodily Injury (ies): (check all that apply)
Scalp
Face
Head
Ear
Eye
Mouth
Nose
Teeth
Tongue
Lip
Forehead
Collar Bone
Neck
Trunk
Ear
Chest
Stomach
Buttocks
Genital Area
Shoulder:
Other (specify): _______________________
Elbow
Arm
Arm
Wrist
Eye
Thumb
Finger
Other (specify): _______________________
Leg
Leg
Ankle
Foot
Knee
Toe
Other (specify): _______________________
R
L
R
L
R
L
Describe Injury
Describe Action Taken
Was medical attention (at hospital or clinic) required?
* Reminder - The provider shall report within twenty-four hours to the county director or the county director's designed a death or serious accident or illness
requiring hospitalization of a child while in the care of the facility or attributable to care received in the facility.
Report Prepared By (Staff Signature)
Date
Parent/Legal Guardian (Signature)
Date
Yes*
No
Copies to: 1) Parent 2) Child's File 3) Incident Log Book