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The Child Care Incident Report form serves as an essential tool for documenting specific incidents and injuries that occur within child care settings. Each report must include critical information such as the child's name, age, and the date and time of the incident. It is vital that this documentation is submitted to the Department of Children, Youth, and Families (DCYF) within 24 hours of the event. Additionally, the form requires details about the provider, including their name and ID, as well as a list of staff members present or any witnesses to the incident. Notably, the form addresses the type of treatment provided to the child while in care and by whom, along with checkbox options to identify situations that necessitated an emergency response. These situations range from inappropriate touching and maltreatment to more severe incidents such as severe injuries or poisoning. A brief description of the incident should also be provided, elaborating on the specifics of what occurred and where. Because parental awareness is crucial, the form includes sections for contacting the child's guardian and for recording comments and acknowledgments from both the parent and the provider, ensuring transparency and accountability in the reporting process.

Child Care Incident Report Example

Child Care Injury/Incident Report

Child’s Name:

In addition to reporting to the department by phone or email about the following incidents and injuries,

a provider must also complete this incident report and submit it to DCYF within 24-hours.

Provider Name

 

 

Provider ID

 

 

 

 

 

 

Child’s Age

Date of Incident

Time of Incident

Incident Occurred

 

 

 

a.m. p.m.

Indoors

Outdoors

 

 

 

 

List names of staff present and/or witnesses:

Treatment provided to child while in care & by who:

 

 

 

 

 

Check All That Apply

Situation that required an emergency response from:

Emergency services (911)

Washington poison center

Department of Health

110-300-0475(2)(b)/110-301-0475(2)(b)

110-300-0475(2)(c)/110-301-0475(2)(c)

110-300-0475(2)(d)/110-301-0475(2)(d)

Situations that occur while children are in care that may put children at risk including, but not limited to:

Inappropriate sexual touching

Physical abuse

Neglect

Maltreatment

Exploitation

Other

 

 

 

 

Serious injury to a child in care:

Severe bleeding

One or more broken bones

Choking or serious unexpected breathing problems

Severe neck/head injury

Sudden unconsciousness

Dangerous chemicals in eyes, on skin, or ingested

Near drowning

Shock or acute confused state

Severe burn requiring professional medical care

Poisoning

Overdose of chemical substance

Injury resulting in overnight hospital stay

Please give a brief description of the injury/incident, including where it occurred.

 

Parent/Guardian Contacted

 

 

 

Licensor Contacted

 

 

Date:

Time:

In Person

Phone

E-mail

Date:

Time:

In Person

Phone

E-mail

 

 

 

 

 

 

 

 

 

 

Parent/Guardian Comments:

Parent/Guardian Signature

Date

By signing this form, I acknowledge that I received a copy of this report.

Licensee/Staff Signature

Date

CHILD CARE INJURY/INCIDENT REPORT

Copiesto: Parent, licensor, licensee

DCYF 15-941 (REV. 6/2021) EXT

 

Form Characteristics

Fact Name Description
Purpose of the Form The Child Care Incident Report form is designed to document injuries or incidents involving children in care. It is crucial for ensuring compliance with safety protocols and regulations.
Submission Timeline Providers must complete and submit this report to the Department of Children, Youth, and Families (DCYF) within 24 hours of the incident.
Information Required The form requires specific details such as the child’s name, age, date, and time of the incident, as well as descriptions of the incident, the treatment provided, and relevant witnesses.
Emergency Response The report includes a section to check if emergency services were involved. This underscores the seriousness of certain situations that may arise, such as severe injuries.
Governing Laws This form is governed by specific regulations including Washington Administrative Code (WAC) sections 110-300-0475(2)(b), 110-300-0475(2)(c), and 110-300-0475(2)(d), which outline mandatory reporting requirements for child care providers.

Guidelines on Utilizing Child Care Incident Report

Filling out the Child Care Incident Report form is an important responsibility that helps ensure transparency and accountability in child care settings. It provides valuable information that needs to be documented and submitted in a timely manner. Once you gather all necessary details, follow these clear steps to complete the form accurately and thoroughly.

  1. Child’s Name: Write down the full name of the child involved in the incident.
  2. Provider Name: Enter the name of your childcare facility or provider.
  3. Provider ID: Include the provider identification number, if applicable.
  4. Child’s Age: Specify the age of the child at the time of the incident.
  5. Date of Incident: Record the date when the incident occurred.
  6. Time of Incident: Note the time of the incident. Indicate whether it occurred a.m. or p.m.
  7. Incident Occurred: Specify whether the incident took place indoors or outdoors.
  8. Staff Witnesses: List the names of all staff present and/or witnesses at the time of the incident.
  9. Treatment Provided: Describe the treatment given to the child while they were in your care, including who administered it.
  10. Emergency Response: Check all applicable situations requiring emergency response, including 911 services, Washington poison center, or Department of Health contacts.
  11. Risk Situations: Check all situations that may put children at risk, such as inappropriate touching or physical abuse.
  12. Serious Injury Description: Indicate if there was a serious injury to the child by checking all applicable types of injuries.
  13. Description of Incident: Provide a brief description of the injury or incident, including the specific location it occurred.
  14. Parent/Guardian Contacted: Mark whether the parent or guardian was contacted, and include date and time. Specify the method of contact (in person, phone, or email).
  15. Licensor Contacted: Indicate if the licensor was contacted with the corresponding date and time, along with the method used.
  16. Parent/Guardian Comments: Allow space for any comments from the parent or guardian regarding the incident.
  17. Parent/Guardian Signature: Have the parent or guardian sign and date the form to acknowledge receipt.
  18. Licensee/Staff Signature: Lastly, include a signature and date from the licensee or staff member completing the report.

Once the form is filled out, ensure it is submitted to the Department of Children, Youth, and Families (DCYF) within the specified 24-hour timeframe. Keeping the communication transparent will not only fulfill compliance requirements but also build trust with parents and guardians.

What You Should Know About This Form

What is a Child Care Incident Report?

The Child Care Incident Report is a formal document designed to record specific incidents or injuries that occur within a childcare setting. This report ensures that both caregivers and authorities are informed about notable events, allowing for appropriate actions and oversight to maintain child safety.

When do I need to submit this report?

The report must be completed and submitted to the Division of Children, Youth, and Families (DCYF) within 24 hours of the incident or injury. Timely submission helps ensure the situation is properly evaluated and addressed.

What information is required on the form?

The form requires detailed information, including the child’s name, age, the date and time of the incident, and a description of what occurred. It also asks for names of staff or witnesses present, treatment given, and should capture vital information regarding any emergency services involved.

Who is responsible for filling out the report?

What types of incidents need to be reported?

The report must include any incident that results in significant harm or injury to a child. This includes severe injuries like broken bones, choking, poisoning, or any situation that may pose a risk, such as maltreatment or inappropriate contact.

How should the incident be described?

A brief description is required, detailing the nature of the incident, where it occurred, and the circumstances surrounding it. Clarity in the description helps authorities understand the context and decide if further investigation is needed.

Do parents or guardians need to be involved in the report process?

Yes, it is essential to contact the child's parent or guardian about the incident. The report includes a section for parent/guardian comments and requires their signature to acknowledge receipt of the report.

What happens if the report is not submitted on time?

Failing to submit the report within the required timeframe can result in non-compliance with regulations, which may lead to penalties or increased scrutiny from authorities. It is crucial to prioritize timely reporting.

Is this report confidential?

While the report does contain sensitive information, it is typically shared with relevant parties, such as parents, licensing officials, and child welfare services as needed. Ensuring confidentiality when handling these documents remains important.

Where do I submit the completed report?

The completed report should be submitted to the DCYF. Specific submission methods may vary, so reviewing the guidelines provided by your childcare licensing agency is recommended for accuracy.

Common mistakes

Filling out the Child Care Incident Report form can be straightforward, but common mistakes can lead to unnecessary complications. One major error is not providing complete information about the child involved. It's crucial to include the child's name, age, and the exact date and time of the incident. Omissions in this area can create confusion and hinder effective communication between child care providers and regulatory agencies.

Another frequent mistake is failing to accurately describe the incident. The section requesting a brief description should capture key details about what happened. Avoid vague language; instead, be clear about the circumstances surrounding the incident. This helps to ensure that everyone understands the context, which is vital for providing additional care and preventing future occurrences.

A third error is neglecting to report whether emergency services were contacted. If a situation required calling emergency services, it must be explicitly noted. This information is not just procedural; it impacts how the case is handled moving forward. If emergency services or other authorities were involved, include relevant details about their response to provide a comprehensive record.

Lastly, many people overlook the importance of signatures from both the parent/guardian and the staff member completing the form. Without these signatures, the report may lack the necessary verification. Ensure that both parties acknowledge the report’s contents, confirming that all information is accurate and agreed upon. This practice safeguards against disputes and enhances accountability.

Documents used along the form

When managing child care incidents, it is crucial not only to complete the Child Care Incident Report form but also to utilize other forms and documents to ensure a comprehensive response and proper documentation. Below is a list of essential forms that are often used in conjunction with the incident report. Each item plays a significant role in following up on the incident and ensuring both accountability and care.

  • Accident Report Form: This document provides a detailed account of an accident within the child care facility. It captures information about the incident, including date, time, and the circumstances leading to the event.
  • Emergency Medical Authorization Form: This form grants permission to seek medical treatment for a child in case of an emergency. Parents or guardians fill it out, ensuring that immediate care can be provided without delay.
  • Child Health Record: This record contains important health information about each child, including allergies, chronic conditions, and recent medical visits. It aids caregivers in assessing a child's health needs during an incident.
  • Notification of Incident Notice: This notification template is sent to parents or guardians about the incident. It serves to inform them and is a critical step in maintaining transparent communication between providers and families.
  • Staff Incident Report: When incidents involve staff or require their involvement, this report outlines the staff member's perspective and actions taken during the event, allowing for a clearer understanding of the circumstances.
  • Witness Statements: If there were witnesses to the incident, collecting their statements can provide valuable insight into what occurred. This documentation can clarify details that may be essential for reporting or resolving any related issues.
  • Incident Follow-Up Form: This form is used to document any actions taken after the incident, including changes in procedures or additional training for staff, enhancing the overall safety and care environment.
  • Insurance Claim Form: Should the incident result in medical expenses, this form is submitted to the child care provider’s insurance company. It helps in recovering costs associated with injuries sustained during care.

Utilizing these documents in conjunction with the Child Care Incident Report helps ensure that incidents are thoroughly documented, providing vital information to parents and staff while enhancing the safety and well-being of all children involved. Proper documentation allows for reflection on the incident and drives improvements in care practices.

Similar forms

  • Child Medical Report: Similar in purpose, this document records injuries, treatments, and medical care provided to a child in a healthcare setting, capturing essential details immediately following a medical incident.
  • Accident Report Form: Often used in various environments, this form captures the details of accidents that occur, including the who, what, when, and where of each incident, similarly to the Child Care Incident Report.
  • School Incident Report: This form is used to document incidents within a school setting. It includes information about students involved, staff present, and actions taken during and after the incident, paralleling the reporting requirements of child care incidents.
  • Workplace Injury Report: In employment settings, this document records injuries that occur on the job. Just like the Child Care Incident Report, it highlights specifics of the incident, including affected parties and any treatments administered.
  • Child Protection Report: This report documents concerns regarding child welfare and safety. It includes details about the incident and involved parties, ensuring that appropriate actions are taken to protect the child.
  • Emergency Response Report: Created after emergencies, this document provides a detailed account of the event's circumstances and the response, echoing the emergency situations outlined in the Child Care Incident Report.
  • Hospital Admission Report: This form documents the reason for hospitalization and initial assessments made on a child entering a hospital, much like the Child Care Incident Report notes the circumstances leading to medical attention.
  • Parent Communication Log: This logging tool records communications and concerns between parents and caregivers, capturing essential details regarding incidents and follow-ups, which are similarly essential in childcare settings.
  • Behavior Incident Report: Common in educational environments, this report details concerning behaviors exhibited by children, documenting incidents that could impact their safety and well-being, similar to reporting specific situations in child care.

Dos and Don'ts

When filling out the Child Care Incident Report form, there are important guidelines to follow. Below is a list of things to do and things to avoid.

  • Do provide accurate information about the child, including their name and age.
  • Do include detailed descriptions of the incident, including where it occurred.
  • Do list all staff present and any witnesses to the incident.
  • Do check all relevant emergency response situations that apply.
  • Do submit the report within 24 hours of the incident.
  • Do collect signatures from the parent/guardian and licensee/staff.
  • Do notify the parent/guardian immediately about the incident.
  • Don’t provide vague descriptions; be specific about what happened.
  • Don’t omit any details about the treatment provided to the child.
  • Don’t delay in reporting the incident; follow the 24-hour timeframe.

Following these steps will help ensure that the report is completed accurately and submitted promptly.

Misconceptions

Misconceptions regarding the Child Care Incident Report form can lead to confusion and mishandling of important information. Here are eight common misconceptions, alongside clarifications:

  1. All incidents must involve serious injuries. The report needs to be filled out for any incident, regardless of the severity. This helps ensure full transparency and proper management.
  2. Only physical injuries need reporting. Other incidents, such as emotional or psychological harm, may also warrant completion of the report, particularly if they may impact the child's well-being.
  3. The form is optional. Completing the report is a mandatory requirement. Providers must submit it to the DCYF within 24 hours of the incident.
  4. Only licensed care providers need to fill it out. Anyone responsible for the child’s care, whether licensed or not, is obligated to report incidents that occur under their supervision.
  5. Submitting the report absolves providers from responsibility. While reporting is crucial, it does not eliminate the moral or legal responsibilities care providers have towards child safety and wellbeing.
  6. Parent notification is not necessary if the child is not seriously injured. Parents should always be informed about any incident or injury, even if it seems minor, to maintain open communication and trust.
  7. Witness names are not important. Documenting witnesses is essential. It provides additional context and may clarify the situation if questions arise later.
  8. The form must be filled out at the time of the incident. While it is best to document the incident as it happens, it can be completed shortly afterward, but it must be submitted within the required timeframe.

By addressing these misconceptions, child care providers can ensure compliance with regulations and foster a safer environment for the children in their care.

Key takeaways

When filling out and utilizing the Child Care Incident Report form, keep the following key points in mind:

  • Timeliness is Crucial: Ensure that the report is completed and submitted to DCYF within 24 hours of the incident. Delays in reporting can have serious implications for both the child and the care facility.
  • Thorough Documentation: Provide a detailed description of the incident, including where it occurred and any treatment that was administered. This detailed account is essential for understanding the situation and informing necessary follow-up actions.
  • Emergency Response Checks: Be diligent in checking all that apply when indicating if emergency services were contacted. This helps create a comprehensive record of the incident response.
  • Accurate Witness Information: List the names of all staff present and any witnesses. This information can be critical in verifying the incident and providing further context if needed.
  • Parent/Guardian Communication: Note the details of parent or guardian contact, including time and method. Documentation of this communication shows that families are kept informed and involved after an incident involving their child.