Child Care Reportable Incident Form
Facility Details
(as it appears on the licence)
(including city)
(for follow up)
(mm/dd/yyyy)
Details
Child(ren) Involved Date of Birth (mm/dd/yyyy) Name of other persons involved / witnessed the incident Indicate relationship: employee, parent, volunteer, etc.
Incident type(s) - Refer to Child Care Licensing Regulation Schedule H for reportable incident definitions
Incident type(s) - Refer to Child Care Licensing Regulation Schedule H for reportable incident definitions
(What occurred leading up to the incident, details of the incident, including where it occurred, what occurred directly after the incident? Submit additional page(s) as needed.)
(Describe the actions completed in follow up to the incident, including how future risk will be mitigated i.e. physical repairs, care plan changes, assessments or referrals, etc.)
Notification
Date (mm/dd/yyyy) Time
Licensing
Parent/Guardian
RCMP/Police
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