Accident Report
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1ACCIDENT REPORT
Child’s Name:
Date of Accident:
Time of Accident:
Nature of Injury:
Location of Incident:
What the child was doing:
Caregiver response and first aid:
Name of Caregiver that responded:
Additional Information:
Parent contacted?
Yes
No
Name of Parent contacted:
Who contacted parent:
How parent was contacted:
Phone
Email
Other:
Time parent was contacted:
Other Contacts or Actions:
Child Care Provider Signature
Date:_____________________
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