ACCIDENT REPORT FORM - SAMPLE - PDF by vcu83380

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									ACCIDENT REPORT FORM – SAMPLE
Name of LINC Site _____________________________________________________________
Child’s name ____________________________________________________ Age ________
Parent’s name ________________________________________________________________
Date of accident ___________________________         Time of accident ____________________
Describe the injury _____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Describe how the accident occurred _______________________________________________
____________________________________________________________________________
____________________________________________________________________________
What First Aid was given? _______________________________________________________
____________________________________________________________________________
Additional comments ___________________________________________________________
____________________________________________________________________________
____________________________________________________________________________


Witness’s name _______________________________________________________________
Signature ____________________________________________________________________
Staff member completing this report _______________________________________________
Signature of staff member _______________________________________________________
Date report completed ______________________

I have been informed of this accident.
Parent’s name ________________________________________________________________
Parent’s signature _____________________________________________________________
Date ____________________________________


Disclaimer
Please review our disclaimer before using any information in this document:
http://www.cmascanada.ca/servicesresources/cmasresources/.

CMAS – Childminding Monitoring Advisory & Support                                  Page 1/1
17 Fairmeadow Avenue, Suite 211 Toronto, Ontario M2P 1W6
Phone 416-395-5027 Fax 416-395-5190 info@cmascanada.ca www.cmascanada.ca
Project Funded by Citizenship & Immigration Canada                                  2008-01

								
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