{"id":294,"date":"2021-11-02T23:32:14","date_gmt":"2021-11-02T23:32:14","guid":{"rendered":"https:\/\/pressbooks.ccconline.org\/accece\/back-matter\/appendix-d-example-injury-incident-report-form\/"},"modified":"2021-11-02T23:32:14","modified_gmt":"2021-11-02T23:32:14","slug":"appendix-d-example-injury-incident-report-form","status":"publish","type":"back-matter","link":"https:\/\/pressbooks.ccconline.org\/accece\/back-matter\/appendix-d-example-injury-incident-report-form\/","title":{"raw":"Appendix D: Sample Injury\/Incident Report Form","rendered":"Appendix D: Sample Injury\/Incident Report Form"},"content":{"raw":"

Example Injury\/Incident Report Form<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Date Incident Occurred\n\n <\/td>\nTime Incident Occurred:<\/td>\n<\/tr>\n
Child\u2019s Name:\n\n <\/td>\nAge:<\/td>\n<\/tr>\n
Adults that observed:\n\n <\/td>\n<\/tr>\n
Where incident occurred: (describe location and any equipment)\n\n <\/td>\n<\/tr>\n
Cause of injury: (description what happened beforehand and\/or hazards involved)\n\n <\/td>\n<\/tr>\n
Description of injury: (what type of injury and the part\/s of body injured)\n\n <\/td>\n<\/tr>\n
Description of first aid given:\n\n <\/td>\n<\/tr>\n
Was medical treatment required?\u00a0\u00a0  No\u00a0\u00a0\u00a0\u00a0 \u00a0 Yes (please describe)\n\n <\/td>\n<\/tr>\n
Follow-up plan for care of the child (if needed):\n\n <\/td>\n<\/tr>\n
Corrective action needed to prevent reoccurrence:\n\n <\/td>\n<\/tr>\n
Parent\/Guardian that was contacted:\n\n <\/td>\nTime:<\/td>\n<\/tr>\n
Notified by:<\/td>\nContact method:\u00a0\u00a0\u00a0  Phone\u00a0\u00a0\u00a0\u00a0 \u00a0 In person\n\n <\/td>\n<\/tr>\n
Staff Signature:\n\n <\/td>\nDate:<\/td>\n<\/tr>\n
Parent\/Guardian Signature:\n\n <\/td>\nDate:<\/td>\n<\/tr>\n<\/tbody>\n<\/table>","rendered":"

Example Injury\/Incident Report Form<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Date Incident Occurred<\/p>\n

 <\/td>\n

Time Incident Occurred:<\/td>\n<\/tr>\n
Child\u2019s Name:<\/p>\n

 <\/td>\n

Age:<\/td>\n<\/tr>\n
Adults that observed:<\/p>\n

 <\/td>\n<\/tr>\n

Where incident occurred: (describe location and any equipment)<\/p>\n

 <\/td>\n<\/tr>\n

Cause of injury: (description what happened beforehand and\/or hazards involved)<\/p>\n

 <\/td>\n<\/tr>\n

Description of injury: (what type of injury and the part\/s of body injured)<\/p>\n

 <\/td>\n<\/tr>\n

Description of first aid given:<\/p>\n

 <\/td>\n<\/tr>\n

Was medical treatment required?\u00a0\u00a0  No\u00a0\u00a0\u00a0\u00a0 \u00a0 Yes (please describe)<\/p>\n

 <\/td>\n<\/tr>\n

Follow-up plan for care of the child (if needed):<\/p>\n

 <\/td>\n<\/tr>\n

Corrective action needed to prevent reoccurrence:<\/p>\n

 <\/td>\n<\/tr>\n

Parent\/Guardian that was contacted:<\/p>\n

 <\/td>\n

Time:<\/td>\n<\/tr>\n
Notified by:<\/td>\nContact method:\u00a0\u00a0\u00a0  Phone\u00a0\u00a0\u00a0\u00a0 \u00a0 In person<\/p>\n

 <\/td>\n<\/tr>\n

Staff Signature:<\/p>\n

 <\/td>\n

Date:<\/td>\n<\/tr>\n
Parent\/Guardian Signature:<\/p>\n

 <\/td>\n

Date:<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n","protected":false},"author":32,"menu_order":4,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"back-matter-type":[27],"contributor":[],"license":[],"class_list":["post-294","back-matter","type-back-matter","status-publish","hentry","back-matter-type-appendix"],"_links":{"self":[{"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/pressbooks\/v2\/back-matter\/294","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/pressbooks\/v2\/back-matter"}],"about":[{"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/wp\/v2\/types\/back-matter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/wp\/v2\/users\/32"}],"version-history":[{"count":0,"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/pressbooks\/v2\/back-matter\/294\/revisions"}],"metadata":[{"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/pressbooks\/v2\/back-matter\/294\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/wp\/v2\/media?parent=294"}],"wp:term":[{"taxonomy":"back-matter-type","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/pressbooks\/v2\/back-matter-type?post=294"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/wp\/v2\/contributor?post=294"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.ccconline.org\/accece\/wp-json\/wp\/v2\/license?post=294"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}