Injury Report Form - Department Of Early Education And Care - Massachusetts

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Injury Report Form
Program_______________________________________
EEC Program #____________________
Address_______________________________________
Telephone #______________________
Administrator/Site Coordinator__________________________________
Section One: to be completed for each injury occurring at the center
Child's Name_____________________________________ Date of Birth___________________
Date of injury____________________________
Time of injury__________________
Description of injury__________________________________________________________________________
___________________________________________________________________________________________
How did injury occur?_________________________________________________________________________
___________________________________________________________________________________________
If applicable, description of equipment involved (location, condition)___________________________________
___________________________________________________________________________________________
Where did injury occur? (Playground, classroom A)__________________________________________________
What group was the child in when injury occurred? _________________________________________________
Number of children in the group?___________
Names & qualifications of staff supervising the group when injury occurred?_____________________________
___________________________________________________________________________________________
Who witnessed/observed injury?________________________________________________________________
Staff present at time of injury?__________________________________________________________________
Who administered first aid?____________________________________________________________________
What first aid was administered? _______________________________________________________________
__________________________________________________________________________________________
Was parent/guardian notified? Yes____ No____
How?_______________
Time?________________
Was anyone else notified? Who?_______________ How?______________
Time?________________
Description of any corrective action taken to prevent similar occurrence ________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Section Two: to be completed in addition to Section One when medical treatment is received
Was 911 called? Yes____ No____
Was child transported for medical attention? Yes____ No____
Where?______________________________________ By Whom?_____________________________________
What treatment was provided? (be specific) _______________________________________________________
___________________________________________________________________________________________
Diagnosis of child? ___________________________________________________________________________
Did child return? Yes_____ No___ When?_________________________________________________________
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE:
Signature of person who completed form_______________________________ Date_________________
Signature of administrator who reviewed form___________________________ Date_________________
Signature of Parent/Guardian_________________________________________ Date_________________
Submitted to EEC within 5 business days if child receives medical treatment:
Placed in child's file______
Entered in record of incidents______
Injury report______
Copy provided to parents_____
Copy of First aid cards for staff involved_____
If applicable, supporting documentation________
EEC USE
: Licensor Review: Initials _____________ Date____________

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