Title Page

  • Student / Child's Full Name

  • Conducted on (Date and Time)

  • Teacher's Full Name

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)

Sign Off

  • Witnesses of the incident

  • Witness
  • Witness' Full Name and Signature

  • Medical Personnel

  • Teacher's Full Name and Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.