• Incident / Injury / Trauma

  • Child's Full Name

  • Child's Date of Birth

  • Child's Room / Group

  • Circumstances Incident / Injury / Trauma

  • Products or Structures Involved

  • Location of Incident

  • Name of Educator Witness to incident

  • Date and Time of Incident

  • Signature Of Witness

  • Nature of Injury Sustained - BE SPECIFIC

  • Details of Action Taken- specific to the environment and injury e.g. remove hazard, help child to their feet, comforted the child, seek help from other educator (this is not about first aid)

  • First Aid Measures taken

  • Name of the Educator completing form

  • Signature of Educator completing form

  • Date and Time record completed

  • Name of Parent notified

  • How where they notified (phone call, face to face)

  • Date and Time Parent notifed

  • Name of Director / Person In Charge Notified

  • Date and time of Director / person in Charge Notification

  • Regulatory Authority Notified (if Applicable)

  • To be completed By Parent. Enter your Full Name to acknowledge notification of this incident

  • Date and Time of Notification

  • Parent Signature

  • Additional Comments (if required)

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