State of Montana
(Revision 8-08)
Department of Public Health and Human Services
Quality Assurance Division – Licensure Bureau
Child Care Licensing
ACCIDENT / INJURY REPORT
*Accidents causing injury to a child which result in the child being hospitalized, requiring ambulance transport or intervention, or
physician treatment must be reported to the appropriate local office of the department within 24 hours. ARM 37.95.183(5)
*A notation of all injuries must be made in the child’s medical record. ARM 37.95.183(6)
Facility Name:
PV#:
Name of Injured Child:
Birth Date:
Date of Accident / Injury:
Time of Injury:
Location of Accident / Injury:
Describe incident: (what was the child doing at the time he/she was injured, condition of premises, what happened)
Type of injury and body part injured:
Staff person(s) responsible for supervision of injured child at time of injury:
– SEE REVERSE SIDE –
State of Montana
(Revision 8-08)
Department of Public Health and Human Services
Quality Assurance Division – Licensure Bureau
Child Care Licensing
ACCIDENT / INJURY REPORT
*Accidents causing injury to a child which result in the child being hospitalized, requiring ambulance transport or intervention, or
physician treatment must be reported to the appropriate local office of the department within 24 hours. ARM 37.95.183(5)
*A notation of all injuries must be made in the child’s medical record. ARM 37.95.183(6)
Facility Name:
PV#:
Name of Injured Child:
Birth Date:
Date of Accident / Injury:
Time of Injury:
Location of Accident / Injury:
Describe incident: (what was the child doing at the time he/she was injured, condition of premises, what happened)
Type of injury and body part injured:
Staff person(s) responsible for supervision of injured child at time of injury:
– SEE REVERSE SIDE –
line
Witnesses to the accident / injury:
Name:
Name:
Name:
Name:
What first aid action was taken?
Date first aid provided:
Time first aid provided:
Name of staff person who administered first aid:
Where was the child taken after the accident?
How was the child transported?
Who transported the child?
What, if any, medical treatment was administered?
Method of parent notification:
Date of parent notification:
Time of parent notification:
PARENT SIGNATURE
DATE
STAFF / WITNESS SIGNATURE
DATE
STAFF / WITNESS SIGNATURE
DATE
STAFF / WITNESS SIGNATURE
DATE
STAFF / WITNESS SIGNATURE
DATE
DIRECTOR / STAFF SIGNATURE
DATE
ADVERTISEMENT