Unit Two Creating a Safe and Healthful Environment
Copyright Goodheart-Willcox Co., Inc.
Figure 11.13
Injury Report Form
Child and Family Study Center
Child’s Name: ______________________________________________________________
Date of injury: _____________________ Time of injury: _____________________ a.m./p.m.
Type of injury: bite, broken bone, bruise, burn, choking, cut, ear, eye, head, poisoning, scrape,
sliver, sprain,
other _____________________________________________________________________
Staff members present: ______________________________________________________
Witness(es): _______________________________________________________________
Description of the incident: (Include specific information, such as where the child was playing,
with whom, and with what.)
Description of injury: (Include specific information, such as type, location, size, and severity of
injury and symptoms noted following injury.)
Action taken by staff: (Include all actions, such as treating injury, seeking medical advice or
care, comforting child, and notifying director and parents.)
(staff signature)
(parent signature)
Center directors and staff must keep constant
watch over the center environment. They must
ensure that it is safe as well as healthy. New
teachers will need constant support from the staff
and director.
Every center should develop a number of
forms related to the health and safety of the
children. Many of these forms direct the staff
in the care of the children and protect staff
members from possible liability. Two forms
commonly used by centers are injury report
forms and various types of release or permission
Every center should have a standard injury
report form. Any information recorded on this
form is useful if legal action is brought against
the center. Parents also need to be informed
about the details of a child’s accident. A sample
form is shown in Figure 11.13.
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