TYPE OF REPORT Incident Accident Illness Death Fire FACILITY Registration/License Number Facility Phone Number ( ) Facility Type Family Child Care Home Facility/Home/Provider Name Group Child Care Home Address (Street Number and Name) County City State Child Care Center Zip Code Children’s Camp Adult Foster Care Camp CHILD(REN) IN CARE INVOLVED Name Name Birthdate Sex Birthdate M F M Home Address (Street Number Name) City Zip Code Name of Parent City State Alternative Phone Number ( ) Home Phone Number ( ) CAREGIVER(S) / OTHER PERSON(S) INVOLVED / WITNESS(ES) Name Address (Street Number, Name, City) Address (Street Number, Name, City) Phone Number Phone Number ( ( ) ) INCIDENT DETAILS Time A.M. Location P.M. Describe the incident..
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