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DEPARTMENT OF CHILDREN AND FAMILIES Division of Early Care and Education dcf.wisconsin.gov Incident Report – Regulated Child Care Centers Use of form: This form is voluntary; however, completion of this form meets the requirements of DCF 202.08(1)(c)1., 250.04(3)(a), 251.04(3)(a) and 252.41(2)(a) of the Wisconsin Administrative Codes. Failure to comply may result in an enforcement action or issuance of a noncompliance statement. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m), Wis. Stats.]. Instructions: The licensee / certified provider shall report any death of a child in care, or any incident or accident that occurs while the child is in care that results in an injury that requires professional medical treatment. Licensee shall notify the department within 48 hours of becoming aware of the medical treatment. Certified provider shall notify the certifying agency as soon as possible but no later than the agency’s next working day. Submit a completed form to the regional licensing / certification office. Retain a copy in the child’s record. CHILD CARE CENTER INFORMATION Name – Child Care Center / Certified Provider Facility / Provider Number Telephone Number Address – Child Care Center / Certified Provider (Street, City, State, Zip Code) CHILD AND PARENT INFORMATION Name – Child Birthdate (mm/dd/yyyy) Name – Parent(s) / Guardian(s) Telephone Number – Child' Home s Telephone Number – Parent / Guardian – Home INCIDENT INFORMATION Incident Location Telephone Number – Parent / Guardian – Work Incident Date Incident Time A.M. Names – Adult Witnesses Incident Description Nature and Extent of Injury If a Toy was Involved in the Incident – Name and Type Activity in Which Child was Engaged When Incident Occurred – Describe How Parent was Notified of Incident – Describe (Include date and time) Action Taken (e.g., first aid, clean up, decontamination, etc.) MEDICAL INFORMATION Name – Hospital or Clinic Name – Physician Address – Hospital or Clinic (Street, City, State, Zip Code) Medical Treatment Provided by Medical Professional – Describe SIGNATURE – Child Care Center Representative / Certified Child Care Provider FOR DEPARTMENT USE ONLY Yes No Is additional investigation required? If "Yes" attach written report. SIGNATURE – Licensing Specialist / Certification Worker Date Reviewed DCF-F-CFS0055-E (R. 01/2013) Date Signed P.M.