- THIS FORM MUST BE COMPLETED AND SIGNED BY STAFF MEMBER PARENT ON THE SAME DAY OF THE INCIDENT PROVIDE PARENT WITH A COPY OF THE INCIDENT REPORT RETURN ORIGINAL TO MENTAL HEALTH SPECIALIST FOR CHILDPLUS ENTRY FORM WILL BE RETURNED TO THE CENTER FOR FILING IN CHILD’S FILE PLEASE USE FIRST AND LAST NAMES FOR CHILD, WITNESSES, TEACHER, OTHER ADULTS PRESENT Name of child: Center: Date/day of incident: Activity: Time of incident: □ Arrival □ Meals □ Quiet time/Nap □ Outdoor play □ Special activity/ Field trip □ Self-care/Bathroom □ Transition □ Classroom jobs □ Circle/Large group activity □ Small group activity □ Centers/indoor play □ Diapering □ Departure □ Clean-up □ Therapy □ Individual activity □ Other Who witnessed incident Adults present: Name Name Describe the occurrence: Strategy/Response: (Please specify verbal reminder, provided physical comfort, reteach/practice expected behavior etc.,) Did child injure another child □ Yes □ No Was a Child Accident Report Form completed for the other child □ Yes □ No Report prepared by: Name Signature Was the parent/guardian notified □ Yes □ No Signature of Parent/Guardian
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