Kinship Incident Report

Child Name:
First Last
Phone:
Volunteer Name:
First Last
Phone:
Date of injury?
MM slash DD slash YYYY
Time of injury?

: Hours

Minutes

AM/PM
Where?
Injury site:
Type of Injury?
Description of Injury:
How did injury happen? Describe what you and others observed. What was the child doing? Where was the child? Please give a complete description of facts:
First aid treatment by:
Who took action?
First Last
Parent/Guardian notified?
Parent/Guardian:
First Last
Notified by:
First Last
What time was parent notified?

: Hours

Minutes

AM/PM
How was parent notified?
Date
Type Name
Signature