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Incident or Existing Injury Form
Parent/ carer to complete this record on arrival to James Farm, if their child has had an injury or accident while not in the setting. All information to be shared with the staff caring for the child
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* Indicates required question
Email
*
Your email
Full Name of Child
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
Date of Incident:
*
MM
/
DD
/
YYYY
Time of Incident:
*
Time
:
AM
PM
Place of incident:
*
Your answer
Description of what happened:
*
Your answer
What led to this incident:
*
Your answer
Who was present at time of incident (including all adults/children/animals)
*
Your answer
What actually happened?
*
Your answer
How was the incident dealt with at the time of event?
*
Your answer
Any history of similar incidents to the child?
*
Your answer
Name of who dealt with the incident at the time
*
Your answer
Relationship of the above person to child? Eg parent, grandparent etc
*
Your answer
Nature of injury
*
Your answer
Treatment given at the time
*
Your answer
Advice given to staff for further care required
*
Your answer
Medical aid sought if any/ a&e attended / doctors/ nurse?
*
Your answer
Future prevention/actions -
eg How can you help to prevent any future similar incidents occuring
*
Your answer
Parent/carer Full name
*
Your answer
Office Use: Staff Recieved & Understood incident, Staff Full Name
Your answer
A copy of your responses will be emailed to the address you provided.
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