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Child Injury Report Template
Clearly record child injury incidents for safety, compliance, and communication with parents or guardians.
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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):
[Step or event]
[Step or event]
[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]
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Learn more about
Child Injury Report Template
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
Click below for detailed info on the template.
For quick answers, scroll below to see the FAQ.
CHILD INJURY REPORT TEMPLATE FAQ
What is a child injury report?
A child injury report is a written record of an incident where a child is hurt or shows signs of injury while in the care of a school, daycare, camp, sports team, or other program. It documents when and where the injury happened, what occurred, what injuries were observed, what care was provided, and who was notified.
Who should complete a child injury report?
A child injury report is usually completed by the adult who witnessed the incident or the staff member responsible for the child at the time, such as a teacher, coach, counselor, childcare worker, or supervisor. In some settings, a manager, nurse, or safety officer may review and sign the report as well.
What should be included in a child injury report form?
A helpful child injury report form typically includes: the child’s name and age, date and time of the incident, location, activity at the time, detailed description of what happened, type and location of injury, first aid or medical care provided, witness information, parent or guardian notification details, and signatures from staff and parents. Some programs also add a section for follow-up actions to prevent similar incidents.
When is a child injury report used?
Child injury reports are used whenever a child is hurt, shows signs of injury, or is involved in an incident that could reasonably have caused injury. This includes falls, collisions, sports injuries, playground accidents, equipment failures, or incidents between children. Programs may require a report even for minor injuries such as small cuts or bruises, especially if parents need to be informed.
Is a child injury report a legal or medical document?
A child injury report is primarily an internal documentation and communication tool for schools, childcare providers, and youth programs. It may be reviewed by parents, administrators, insurers, or legal representatives if questions arise about what happened. It does not replace official medical records or legal reports, and serious injuries or suspected abuse must be handled according to local laws and child-protection procedures.
Can AI Lawyer help me create or adapt a child injury report for my program?
Yes. AI Lawyer can help you structure and adapt a child injury report form by suggesting clear sections, wording, and layout that fit your school, daycare, camp, or sports program. You decide what information to collect and how to follow local laws and policies, and AI Lawyer helps format it into a professional document. For specific legal, medical, or child-safety questions, you should consult qualified professionals rather than relying on this template.
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