Child Injury Report Template

[Program / School / Organization Name]
[Program Address]
[City, State/Province, ZIP/Postal Code]
Phone: [Phone Number]
Email: [Email Address]

1. Child Information

Child’s Full Name: [Name]
Date of Birth: [MM/DD/YYYY]
Age: [Age]
Gender: [Gender]

Group / Class / Team: [Name or Number]
Primary Teacher / Coach / Counselor: [Name]

2. Incident Date, Time, and Location

Incident Date: [MM/DD/YYYY]
Incident Time: [HH:MM a.m./p.m.]

Location of Incident (room, area, field, playground, etc.): [Location]
Type of Area: [Indoor / Outdoor]

3. Activity at the Time of Injury

Activity or Event: [Example: classroom activity, free play, sports practice, field trip, meal/snack time]

Supervision at Time of Incident:

• Staff Present: [Name(s)]

• Approximate Number of Children Present: [Number]

4. Description of Incident

Provide a clear, factual description of what occurred.

Description of What Happened:
[Free-text narrative]

Sequence of Events (if helpful):

1. [Step or event]

2. [Step or event]

3. [Step or event]

5. Injury Details

Body Part(s) Injured: [Example: forehead, left arm, right knee, etc.]

Type of Injury (check or describe):

• Bump / Bruise

• Cut / Scrape / Abrasion

• Sprain / Strain

• Suspected Fracture

• Bite / Sting

• Burn

• Other: [Description]

Side of Body (if applicable): [Left / Right / Both / Center]

Visible Signs of Injury:
[Example: redness, swelling, bleeding, discoloration, limited movement]

6. Pain and Child’s Response

Child’s Level of Distress (as observed): [Calm / Upset / Crying / Inconsolable / Other]

Child’s Reported Pain (if verbal): [Child’s own words, if possible]

Behavior After Injury: [Example: continued activity, sat out, lay down, requested parent, etc.]

7. First Aid and Immediate Response

Staff Member(s) Providing Care: [Name(s) and role(s)]

First Aid / Care Provided (check or describe):

• Area cleaned

• Bandage or dressing applied

• Ice pack / cold compress applied

• Rest / observation

• Immobilization / support (e.g., sling, splint)

• CPR or emergency response measures

• Other: [Description]

Was 911 / Emergency Medical Services Called? [Yes / No]
If Yes, Time Called: [HH:MM a.m./p.m.]
Transported to Medical Facility? [Yes / No]
If Yes, Facility Name: [Name of Hospital / Clinic]

8. Witness Information

Witness 1:
Name: [Name]
Role: [Child / Staff / Other]
Contact Information (if applicable): [Phone / Email]

Witness Statement (brief):
[Free-text summary]

Witness 2:
Name: [Name]
Role: [Child / Staff / Other]
Contact Information (if applicable): [Phone / Email]

Witness Statement (brief):
[Free-text summary]

[Add additional witness sections as needed.]

9. Parent / Guardian Notification

Parent / Guardian Name Notified: [Name]
Relationship to Child: [Relationship]

Method of Notification: [In Person / Phone Call / Voicemail / Email / Other]
Date and Time of Notification: [MM/DD/YYYY – HH:MM a.m./p.m.]

Name of Staff Member Who Notified Parent / Guardian: [Name]

Summary of What Was Communicated:
[Free-text summary]

10. Follow-Up and Monitoring

Planned Follow-Up Actions:

• Continue to observe child at program

• Request medical evaluation

• Review safety procedures

• Adjust environment or equipment

• Other: [Description]

Notes on Child’s Condition Before Leaving Program (same day):
[Free-text observation]

11. Staff and Administration Review

Reporting Staff Member:
Name: [Name]
Position: [Title]
Signature: ___________________________ Date: [MM/DD/YYYY]

Reviewing Staff / Administrator (if applicable):
Name: [Name]
Position: [Title]
Signature: ___________________________ Date: [MM/DD/YYYY]

12. Parent / Guardian Acknowledgment (If Required)

I acknowledge that I have been informed of the incident described in this Child Injury Report and have had the opportunity to ask questions.

Parent / Guardian Name: [Name]
Signature: ___________________________ Date: [MM/DD/YYYY]

Preferred Follow-Up Method (optional): [Phone / Email / In Person]

13. Additional Notes or Attachments

Additional Notes:
[Free-text area for any other relevant information]

Attachments (if any):

• Photos of injury or location

• Internal incident forms

• Medical notes or discharge summary

• Other: [Description]