INCIDENT REPORT
NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES
CHILDREN AND FAMILY SERVICES DIVISION
SFN 438 (6-2014)
Location Where Incident Occurred:
Other _____________________________
Describe Equipment Involved (if applicable) (i.e. climber, toy, swing, etc.)
Fall to surface; estimate height of fall _______________; type of surface ______________________; depth of surface ___________________
Fall from running or tripping
Other (specify): ___________________________________________________________________
Type of Injury (ies): (check all that apply)
Other (specify): ___________________________________________________________________
Location of Bodily Injury (ies): (check all that apply)
Other (specify): _______________________
Other (specify): _______________________
Other (specify): _______________________
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)
Parent/Legal Guardian (Signature)
Copies to: 1) Parent 2) Child's File 3) Incident Log Book
Follow-up Plan (if needed)
Name of Legal Guardian or Parent Notified