Title Page
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Conducted on
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Prepared by
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Location
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Incident / Injury / Trauma
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Child's Full Name
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Child's Date of Birth
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Child's Room / Group
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Circumstances Incident / Injury / Trauma
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Products or Structures Involved
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Location of Incident
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Name of Educator Witness to incident
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Date and Time of Incident
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Signature Of Witness
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Nature of Injury Sustained - BE SPECIFIC
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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)
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First Aid Measures taken
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Name of the Educator completing form
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Signature of Educator completing form
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Date and Time record completed
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Name of Parent notified
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How where they notified (phone call, face to face)
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Date and Time Parent notifed
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Name of Director / Person In Charge Notified
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Date and time of Director / person in Charge Notification
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Regulatory Authority Notified (if Applicable)
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To be completed By Parent. Enter your Full Name to acknowledge notification of this incident
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Date and Time of Notification
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Parent Signature
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Additional Comments (if required)
