Incident and Accident Report
This is the centre's own record of one incident. It is not a government form.
A. Centre, child and report
| Centre name | | Report no. | |
| Date report written | | Practitioner in charge | |
| Child full name | | Date of birth | |
| Group or class | | Date of incident | |
B. What happened
| Exact time it happened | | Staff who saw it happen | |
| Exact place | |
| What the child was doing immediately before | |
| What happened, in order. Facts only. | |
C. Injury and first aid
| Did the child strike the head? | YES / NO | If YES, time watching started | |
| Part of body and side | | Description and size in cm | |
| First aid given | |
| Given by | | Time first aid started | |
| Medical attention advised? | YES / NO | What was advised | |
D. Parent or guardian
| Parent notified (name) | | Time phoned, and by whom | |
| What the parent said | |
| Child collected by | | Time collected | |
Other learner involved
Centre copy only | |
E. Action taken so this does not happen again
| Action taken | |
| Done by | | Date completed | |
F. Signatures
| Practitioner who attended | Printed name | Signature | Date |
| Principal or supervisor | Printed name | Signature | Date |
| I was told about this incident, I have read this report, and I received a copy of it. | Copy given to parent: YES / NO |
| Parent or guardian | Printed name | Signature | Date and time |
HEAD INJURY. Phone the parent at once for any knock to the head, even with no bump showing. Send the child for medical attention straight away if the child lost consciousness, vomits, becomes unusually sleepy or hard to wake, or has a fit. Ambulance 10177. From a cellphone 112. Do not move a child you think has hurt the neck or back.