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Your state determines applicable child care licensing regulations and incident reporting requirements

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Daycare Incident Report

[_licensing_label]Report Date: [incident_date_display]

State: [_state_name]

Severity: [incident_severity]

[_serious_label]

SECTION 1: CHILD & INCIDENT DETAILS

CHILD INFORMATION
Child's Name: ________________
Age: ____

INCIDENT DETAILS
Date: ________________ Time: ________
Location: ________________________________
Activity: ________________
Staff-to-Child Ratio: ____
Severity: ________________

Description:
________________________________

Immediate Actions Taken:
________________________________

Parent/Guardian Notified At: ________

SECTION 2: PEOPLE INVOLVED

SECTION 3: WITNESSES

No witnesses identified.

SECTION 4: ROOT CAUSE ANALYSIS

Root Cause:
________________________________

Corrective Actions Planned:
________________________________

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