Parents/legal guardians and state licensing specialists know children are active and no amount of child proofing and supervision can prevent all injuries. The Family Child Care Licensing Rule requires providers to maintain records on incidents/minor injury/accidents as part of a child’s record. The Family Child Care Licensing Rule also requires a serious injury/death report be completed and maintained as part of a child’s record when injuries that require medical treatment by a physician or emergency room, for example, a broken bone, losing consciousness happen. Reporting injuries can help prevent them in the future by identifying injury patterns specific to Growing Together Child Care’s environment, and/or with an individual child who may need help with difficulties associated with balance, vision or foot positioning.
Growing Together Child Care uses different reporting forms for the different level of injury/incident.
Growing Together Child Care will use a Serious Injury/ Accident Reporting Form to report accidents as required by the Licensing Rule. A copy of the completed form will be kept in the child’s file and provided to the child’s parents/legal guardians. The Child’s Parents/Legal Guardians signatures will be secured on the Reporting form within the required 24 hours of the event. Serious injuries are also reported to the Child Care Licensing Unit at 287-9300 within 24 hours. When possible, medical attention is left for the child’s parents/legal guardians to decide on how it will be handled. In the case of an emergency when the Child’s parents/legal guardians cannot be reached the provider will use the Authorization for Medical Care in the child’s record to secure the necessary medical care.
Serious Injury/Death Report
Medical attention required? _____ No/ ____ Yes (If yes, check below)
___ Parent contacted, child remained in center
___ Paramedics treated
___ Transported to hospital by ambulance
___ Parent reported taking child to doctor/clinic
___ Parent reported taking child to emergency room
___ Child admitted to hospital
___ Other
Describe outcome, as reported by parent: (Example: cast, stitches, return to child care date, etc.)
Comments (for example, prevention in future?):
Person reporting injury: Date:
Reported to:
Name of official/agency notified:
Witnesses to Injury, print name(s):
Parent/Legal Guardian Signature(s) and date(s) signed:
Incident/Accident Report: Use this form to report accidents to the injured child’s parents/legal guardians as required. Keep a signed copy in the child’s file.
Name of program/operator:
Address of program:
Name of injured child:
Child’s date of birth:
Gender: Male Female Were there other children involved? Yes No
Date of injury: Time of Injury: am pm
Circle where injury occurred: playground in facility field trip during transport
Location details:
Circle during what activity: Outdoor free play Outdoor organized play Water play Indoor
Free play Indoor organized play going up/down stairs Meal/snack Naptime Bathroom
Activity details:
Equipment involved, if any:
Result of injury – observed symptom(s):
Circle body area injured: (Circle and note if injury is to the child’s Left or Right) Head Hair Face
Eye L/R Ear L/R Mouth Nose Neck Chest Back Stomach Buttocks L/R Genitals Arm L/R
Hand L/R Left L/R Foot L/R Finger (Specify)
Description of how injury occurred:
Description of first aid administered to child/ by whom:
Parent/Guardian notification Date notified:
Print name(s):
Signature(s): Date:
Growing Together Child Care 