LeapFrog Family Incident Report
Complete this form promptly to document any incident at your childcare center. Please use clear, simple language.
General Information
Center Location
*
Please Select
Children's New World
Kiddie Kollage
Malone's Early Learning Center
Stepping Stones Academy
Childhood Learning Academy
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Person Involved
Who was involved?
Please Select
Child
Staff
Visitor
Other
Name of Person(s) Involved
Type of Incident
Type of Incident
Please Select
Injury
Behavior Issue
Illness
Accident
Safety Concern
Other
Incident Details
Description of What Happened
*
Where did the incident occur?
Was anyone injured?
Yes
No
If yes, describe the injury
Action Taken
What action was taken?
Was first aid given?
Yes
No
Was emergency service called?
Yes
No
Parent Notification
Was the parent/guardian notified?
Yes
No
If yes, how were they notified?
Please Select
Phone
In Person
Email
Other
Witnesses
Were there any witnesses?
Yes
No
If yes, list witness names
Report Completed By
Your Name
*
Your Position
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