Incident Report - Child Care Licensing Act
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CDEV 4029 (2011/04) Page of Incident Report The information collected on this form is collected and managed in accordance to the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection or use of the information, contact your licensing officer. Licence holders and contract holders are required to report serious illness of or injury to a child that occurs while the child is attending a program and any other incident that occurs while a child is attending a program that may seriously affect the health or safety of the child. Incidents that require reporting include, but are not limited to: death of a child, injury, allegation of abuse, missing or lost child, a young person involved in crime, child removed from a program without permission, emergency evacuation or unexpected program closure, intruder on premises, illness or injury requiring emergency medical services and hospitilization, error in the administration of medication, and child left on premises after hours. Incidents must be reported immediately to licensing staff by telephone, fax or email. This form must be completed and submitted to your local Child and Family Services Authority's licensing office within 2 days of the incident. Part 1: Program Information Licence Holder or Contract Holder name Program/Provider Name Program/Provider Address City Province Postal Code Part 2: Child Information Full Name of Child Date of Birth Male Female Child Care Programs
Transcript of Incident Report - Child Care Licensing Act
CDEV 4029 (2011/04) Page of
Incident Report
The information collected on this form is collected and managed in accordance to the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection or use of the information, contact your licensing officer.
Licence holders and contract holders are required to report serious illness of or injury to a child that occurs while the child is attending a program and any other incident that occurs while a child is attending a program that may seriously affect the health or safety of the child. Incidents that require reporting include, but are not limited to: death of a child, injury, allegation of abuse, missing or lost child, a young person involved in crime, child removed from a program without permission, emergency evacuation or unexpected program closure, intruder on premises, illness or injury requiring emergency medical services and hospitilization, error in the administration of medication, and child left on premises after hours.
Incidents must be reported immediately to licensing staff by telephone, fax or email. This form must be completed and submitted to your local Child and Family Services Authority's licensing office within 2 days of the incident.
Part 1: Program Information
Licence Holder or Contract Holder name
Program/Provider Name
Program/Provider Address
City Province Postal Code
Part 2: Child InformationFull Name of Child
Date of BirthMale Female
Child Care Programs
CDEV 4029 (2011/04) Page of
Part 3: Details of IncidentType of Incident
Death Injury Allegation of abuse Missing/lost child Young person involved in crime
Child removed from program without permission Emergency evacuation Unexpected program closure
Intruder on premises Illness/injury requiring emergency medical services and hospitilization
Error in the administration of medication Child left on premises after hours
Date, time and location of incident
Date Time (specify am or pm) Location
Authorities ContactedDate and time ambulance was contacted (if applicable)
Date Time (specify am or pm) By whom
Date and time child taken to hospital (if applicable)
Date Time (specify am or pm) By whom
Date and time police were contacted (if applicable)
Date Time (specify am or pm) By whom
Part 4: Notification
When was the parent/guardian or emergency contact notified of the incident?
Date Time (specify am or pm) Name of parent/guardian notified
Who notified the parent/guardian of the incident?
How was the parent/guardian notified? (ex. By phone, in writing, in person)
List all others who were notified, including authorities such as Police Services, Health Services, and Child Intervention, if applicable.
(i) Name of individual contacted Authority
Contact Telephone Number Office Location
(ii) Name of individual contacted Authority
Contact Telephone Number Office Location
(iii) Name of individual contacted Authority
Contact Telephone Number Office Location
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Staff/individuals who were present at the time of incident
(i) Full Name
Position Contact Telephone Number
(ii) Full Name
Position Contact Telephone Number
(iii) Full Name
Position Contact Telephone Number
(iv) Full Name
Position Contact Telephone Number
(v) Full Name
Position
Number of children present in the group or room at the time of the incident
Contact Telephone Number
Part 5: Description of IncidentDid the incident result in an injury?
Yes No
If 'yes', complete the following:
Type of injury
Body part injured
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Cause of injury
Treatment required
First Aid administered?
Yes No
Date Time (specify am or pm) By Whom
Describe
Activity at time of injury
Provide any additional information about the incident including what happened, who was involved, what action was taken as a result and what follow-up action will be taken.
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Updates (Provide updates on new or additional information relevant to the incident. Use this section of the form or an attachment to document and submit updates to licensing staff.)
Signature of Program Representative Date (yyyy-mm-dd)
For Office Use OnlyReceived by: Date received:
Licensing Staff Member Assigned to: Date assigned:
Follow-up to incident inspection completed by: Date of inspection:
