ACCIDENT/INJURY CENTER NAME: CENTER ADDRESS: REPORT INJURY/ACCIDENT HAPPENED: TREATMENT/ FOLLOW UP...

Click here to load reader

download ACCIDENT/INJURY CENTER NAME: CENTER ADDRESS: REPORT INJURY/ACCIDENT HAPPENED: TREATMENT/ FOLLOW UP ACTIONS:

of 1

  • date post

    11-Aug-2020
  • Category

    Documents

  • view

    3
  • download

    0

Embed Size (px)

Transcript of ACCIDENT/INJURY CENTER NAME: CENTER ADDRESS: REPORT INJURY/ACCIDENT HAPPENED: TREATMENT/ FOLLOW UP...

  • OOL /3.8.2018

    ACCIDENT/INJURY REPORT

    The center shall maintain on file a written record of each incident

    resulting in an injury.

    CENTER NAME: CENTER ADDRESS:

    CHILD’S NAME: PERSON COMPLETING REPORT: WITNESS(ES):

    DATE OF INJURY: TIME OF INJURY: DATE REPORT COMPLETED: TIME REPORT COMPLETED:

    TYPE OF INJURY: (Check All That Apply)

    ACHE BREATHING SHALLOW FOREIGN BODY IN EYE REDNESS BITTEN BY ANIMAL BROKEN BONE SUSPECTED HEAD INJURY SCRAPE BITTEN BY CHILD CHOKING ITCHING SCRATCH BITE THAT BROKE THE SKIN CUT NAUSEA SPLINTER BLEEDING DROWSINESS NOSE BLEED SPRAIN BURN EYE INJURY POISIONING STING BREATHING RAPIDLY FALL FROM A HEIGHT OF: _____ RASH SWELLING OTHER:

    PLACE ON BODY INJURY

    OCCURRED: (Check All That Apply)

    ABDOMEN CHEEK FINGER HEAD MOUTH THIGH ARM CHEST FOOT HIP NECK TOE ANKLE CHIN FOREHEAD KNEE NOSE TONGUE BACK EAR GROIN LEG SHOULDER WRIST BUTTOCKS ELBOW HAND LIP TEETH OTHER:

    WHERE INJURY OCCURRED:

    (Check All That Apply)

    CLASSROOM BATHROOM SIDEWALK CAR FIELD TRIP KITCHEN HALLWAY STAIRWAY PARKING LOT BUS PLAYGROUND OTHER:

    TYPE OF SURFACE CARPETING TILE FLOOR WOOD FLOOR RUBBER LAMINATE FLOOR WOOD CHIPS GRASS SAND CONCRETE ASPHALT OTHER:

    DESCRIBE HOW INJURY/ACCIDENT

    HAPPENED:

    TREATMENT/ FOLLOW UP

    ACTIONS: (Check All That Apply)

    FIRST AID GIVEN AT THE CENTER: OUTSIDE MEDICAL ATTENTION GIVEN: (Notify the OOL by next working day and provide documentation within 1 week.)

    CLEANED WITH SOAP AND WATER ICE APPLIED ANTISEPTIC APPLIED REST PROVIDED BANDAGE APPLIED

    CONSOLED CHILD MEDICATION ADMINISTERED:

    OTHER (DESCRIBE):

    AMBULANCE OR 911 CALLED/ONSITE EMERGENCY CARE PROVIDED POISION CONTROL CALLED TRANSPORTED EMERGENCY/URGENT CARE CONSULTATION/TREATMENT BY LICENSED PHYSICIAN OR HEALTH CARE PROVIDER

    STAFF WHO PERFORMED FIRST AID:

    PARENT NOTIFICATION*:

    METHOD OF NOTIFICATION: NOTIFIED BY PHONE OTHER: NOTIFIED AT PICK UP

    TIME OF NOTIFICATION: COMMENTS:

    ∗ Take immediate necessary action to protect the child from further harm and immediately notify the child's parent(s) when a bite breaks the skin; a child sustains a head or facial injury, including when a child bumps his/ her head; a child falls from a height greater than the height of the child; or an injury requiring professional medical care occurs.

    STAFF SIGNATURE: DATE: DIRECTOR SIGNATURE: DATE: PARENT SIGNATURE: DATE:

     The center shall notify the parent immediately when a child sustains a head or facial injury including when a child bumps his or her head, when a bite breaks the skin, and/or when a child falls from a height greater than the height of the child. Word Bookmarks Check68 Check104 Check110 Check117 Check69 Check105 Check111 Check118 Check70 Check106 Check112 Check119 Check71 Check107 Check113 Check120 Check72 Check108 Check114 Check121 Check73 Check109 Check115 Check122 Check103 Check116 Check123 Check67 Check74 Check79 Check84 Check89 Check94 Check99 Check75 Check80 Check85 Check90 Check95 Check100 Check76 Check81 Check86 Check91 Check96 Check101 Check77 Check82 Check87 Check92 Check97 Check102 Check78 Check83 Check88 Check93 Check98 Check66 Check56 Check63 Check60 Check57 Check59 Check61 Check55 Check62 Check64 Check58 Check65 Check54 Check43 Check46 Check48 Check50 Check52 Check45 Check47 Check49 Check51 Check53 Check44 Check126 Check127 Check128 Check129 Check130 Check124 Check133 Check125 Check1 Check2 Check132

    CENTER ADDRESSACCIDENTINJURY REPORT The center shall maintain on file a written record of each incident resulting in an injury: CHILDS NAMERow1: PERSON COMPLETING REPORTRow1: WITNESSESRow1: DATE OF INJURYRow1: TIME OF INJURYRow1: DATE REPORT COMPLETEDRow1: TIME REPORT COMPLETEDRow1: ACHE: Off BITTEN BY ANIMAL: Off BITTEN BY CHILD: Off BITE THAT BROKE THE SKIN: Off BLEEDING: Off BURN: Off BREATHING RAPIDLY: Off OTHER: Off BREATHING SHALLOW: Off BROKEN BONE SUSPECTED: Off CHOKING: Off CUT: Off DROWSINESS: Off EYE INJURY: Off undefined: Off FALL FROM A HEIGHT OF: FOREIGN BODY IN EYE: Off HEAD INJURY: Off ITCHING: Off NAUSEA: Off NOSE BLEED: Off REDNESS: Off SCRAPE: Off SCRATCH: Off SPLINTER: Off SPRAIN: Off THIGH: Off TOE: Off TONGUE: Off WRIST: Off ABDOMEN: Off ARM: Off ANKLE: Off BACK: Off BUTTOCKS: Off OTHER_2: Off CHEEK: Off CHEST: Off CHIN: Off EAR: Off ELBOW: Off FINGER: Off FOOT: Off FOREHEAD: Off GROIN: Off HAND: Off HEAD: Off HIP: Off KNEE: Off LEG: Off LIP: Off MOUTH: Off NECK: Off NOSE: Off SHOULDER: Off TEETH: Off CLASSROOM: Off BATHROOM: Off SIDEWALK: Off CAR: Off FIELD TRIP: Off KITCHEN: Off HALLWAY: Off STAIRWAY: Off PARKING LOT: Off BUS: Off PLAYGROUND: Off OTHER_3: Off CARPETING: Off TILE FLOOR: Off WOOD FLOOR: Off RUBBER: Off LAMINATE FLOOR: Off WOOD CHIPS: Off GRASS: Off SAND: Off CONCRETE: Off ASPHALT: Off OTHER_4: Off CLEANED WITH SOAP: Off ICE APPLIED: Off ANTISEPTIC APPLIED: Off REST PROVIDED: Off BANDAGE APPLIED: Off CONSOLED CHILD: Off MEDICATION ADMINISTERED: Off OTHER DESCRIBE: Off AMBULANCE OR 911 CALLEDONSITE: Off EMERGENCY CARE PROVIDED: Off POISION CONTROL CALLED: Off TRANSPORTED EMERGENCYURGENT CARE: Off CONSULTATIONTREATMENT BY LICENSED: Off STAFF WHO PERFORMED FIRST AID: NOTIFIED BY PHONE: Off NOTIFIED AT PICK UP: Off OTHER_5: Off TIME OF NOTIFICATION: COMMENTS: STAFF SIGNATURERow1: DATERow1: DIRECTOR SIGNATURERow1: DATERow1_2: PARENT SIGNATURERow1: DATERow1_3: Text3: Text4: Text5: Text6: Text7: Text8: Text9: Description: Center Name A/I Report: POISIONING: 0: Off 1: Off

    STING: 0: Off 1: Off