Injury Reports

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 juries can help prevent them in the future by identifying injury patterns specific to Country Fun Child Care’s environment, and/or with an individual child who may need help with difficulties associated with balance, vision or foot positioning.

Country Fun Child Care uses different reporting forms for the different level of injury/incident.

Country Fun 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 record 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 decision on how it will be handled. In the case of an emergency when the Child’s parents/legal guardians cannot be reached the provider or supervising staff 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: