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Child Care Home Date/Time of Incident Witness to Incident Child Care Center County Name__________________________________________ Child's Name Sex Age _______ Parents Notified By Time Notified

Environmental Factor(s) Involved

Indoors: Block Furniture Cubby Door Floor Medication Toy Other Child Shelving Sink Steps Vehicle N/A Other___________________________________ Outdoors: Bench Climber Fence/Wall Composite Play Structure Deck Swing Other Child Sandbox Sidewalk Slide Surfacing Toy Vehicle N/A Other Playground Equipment__________________________ Other_____________________________________________

Cause of Injury:

Fall from Height Burn Hit By or Bumped Into Object Human Bite Splinter/Foreign Object Pinched/Caught In Sharp/Piercing Object Other:

Type of Injury:

Dental Injury Fracture/Dislocation Cut/Scrape Puncture Sprain/Strain Burn Bite Crush Bump/Bruise Other: Splinter

Body Part Injured:

Head Eye Abdomen/Trunk/Chest Face Leg Mouth Knee Neck Foot/Ankle Arm Other Hand/Wrist/Finger

Where Child Received Treatment:

Clinic Dentist Urgent Care Doctor's Office Other Hospital/ER Onsite By Health Professional

Description of How and Where Incident Occurred & First Aid Received:

Steps Taken to Prevent Reoccurrence

Signature of Staff Member Signature of Parent/Guardian

Date Date

Anytime a Child Receives Medical Treatment as a Result of an Incident Occurring at a Child Care Center or Child Care Home this Report Must be Submitted Within 7 Calendar Days to your Child Care Consultant {Rule 10 NCAC 3U .0802(d);10 NCAC 3U .1717(a)(3)(T)} Original to Child's File Copy to Parent/Guardian Copy to Child Care Consultant Enter into Incident Log

Date of Most Recent Playground Inspection __________________ DCD-0582 3/97


Child Care Consultant's Name


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