Incident Details
Date and Time of Incident

What was the incident/ near miss?

Were there any injuries?

Please identify injured person(s)

Was there any damage to daycare property?

What caused the incident?

Take photos of surrounding environment and include any annotations

Medical Services/Treatment Provided (Please include any and all treatment, listing who administered treatment)

What actions will be taken to eliminate future repeats of the incident?

Teacher's comment(s)

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Witnesses of the incident

Witness' Full Name and Signature
Medical Personnel
Teacher's Full Name and Signature