Child Care Reportable Incident Form Facility Details Facility Details Facility Name (as it appears on the licence) Facility Address City Postal Code? First Name of Person Completing Form Last Name of Person Completing Form Phone Number? Phone Extension (if applicable) Incident Details Incident Details Incident Date Time Clear button4 X Incident type(s) - Refer to Child Care Licencing Regulation Schedule H for reportable incident definitions Incident Type(s) - Refer to Child Care Licensing Regulation Schedule H for reportable incident definitions (Select all that apply) Incident type(s) - Refer to Child Care Licencing Regulation Schedule H for reportable incident definitions Aggressive or Unusual Behaviour Medication Error Attempted Suicide Missing or Wandering Person Choking Motor Vehicle Injury Death Neglect Disease Outbreak or Occurrence Unexpected Illness Emergency Restraint Physical Abuse Emotional Abuse Poisoning Fall Service Delivery Problem Financial Abuse Sexual Abuse Food Poisoning Other Injury Total number of persons in care involved Total Number of Children in Care Involved Child(ren) Involved If the incident is an outbreak or service delivery problem and has 4 or more children in care involved, you do not need to enter the names below. Details First Name Last Name Date of Birth? First Name Last Name Date of Birth? First Name Last Name Date of Birth? Not Witnessed Total Witnesses Involved Please enter 0 if this incident was not witnessed Name of other persons involved / witnessed the incident Indicate relationship: employee, parent, volunteer, etc. Name of other persons involved / witnessed the incident Indicate associate to child in care First Name Last Name - Select -StaffFamilyGuardianVolunteerVisitorOther Relationship to child in care First Name Last Name - Select -StaffFamilyGuardianVolunteerVisitorOther Relationship to child in care First Name Last Name - Select -StaffFamilyGuardianVolunteerVisitorOther Relationship to child in care Detailed Description of Incident Detailed Description of Incident (What occurred leading up to the incident, details of the incident, including where it occurred, what occurred directly after the incident?) License/Manager Actions License/Manager Actions (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 Notification Date Time Licensing Date Time Clear button X Parent/Guardian Date field 2 Time1 Clear button2 X RCMP/Police Date field 3 Time3 Clear button3 X CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Before you submit To keep a copy of your submission, click the Download button before clicking Submit. After you have saved a copy, click to Submit to complete your submission. Download Download
