SAMPLE: Incident Form
Safety & Protection of Minors Resources
INCIDENT/ACCIDENT/INJURY REPORT FORM
Lobs & Lessons
DIVISION OF COMMUNITY ENGAGEMENT
Child’s Name
Age
Date
Time of incident/accident/injury
/
/
Location where incident/accident/injury happened
:
AM
PM
Description of how incident/accident/injury occurred
Parts of body involved
Treatment given/action taken
Treatment given by whom
Name of parent notified
Time parent notified
:
AM
PM
Signature of person notifying parent
Time and date of when Vice Provost notified
:
AM PM
Signature of Employee
Signature of Program Director
/
/
Date
/
/
/
/
Date