Accident Incident Report Form - Childcare Committee - Dublin

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Accident / Incident Report Form
Child’s Name: _________________________________________________Date of birth:____ /____/____
Address: _______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Details of Accident/Incident
Date of accident/incident: _____________________________ Time of accident/incident: ___________
Description of accident/incident: (nature of any injury/illness etc.)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Who was present at time of accident/incident? ______________________________________________
_______________________________________________________________________________________
Witnesses of accident/incident: ___________________________________________________________
_______________________________________________________________________________________
Actions taken and by whom: ______________________________________________________________
_______________________________________________________________________________________
Parents/Guardian contacted
Yes
No
GP contacted
Yes
No
Ambulance / Hospital contacted
Yes
No
Comments/ any follow on action required:
_________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Childminders Signature:________________________________________________ Date:____ /____/____
Parent/ Guardian Signature: ____________________________________________ Date:____ /____/____
These forms should be easily accessible and kept in book format.
These forms have been developed by the City and County Childcare Committees of Dublin City,
Dún Laoghaire Rathdown, Fingal and South Dublin.
Funded by the Irish Government under the National Development Plan 2007-2013
Accident / Incident Report Form
Child’s Name: _________________________________________________Date of birth:____ /____/____
Address: _______________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Details of Accident/Incident
Date of accident/incident: _____________________________ Time of accident/incident: ___________
Description of accident/incident: (nature of any injury/illness etc.)
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Who was present at time of accident/incident? ______________________________________________
_______________________________________________________________________________________
Witnesses of accident/incident: ___________________________________________________________
_______________________________________________________________________________________
Actions taken and by whom: ______________________________________________________________
_______________________________________________________________________________________
Parents/Guardian contacted
Yes
No
GP contacted
Yes
No
Ambulance / Hospital contacted
Yes
No
Comments/ any follow on action required:
_________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Childminders Signature:________________________________________________ Date:____ /____/____
Parent/ Guardian Signature: ____________________________________________ Date:____ /____/____
These forms should be easily accessible and kept in book format.
These forms have been developed by the City and County Childcare Committees of Dublin City,
Dún Laoghaire Rathdown, Fingal and South Dublin.
Funded by the Irish Government under the National Development Plan 2007-2013

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