Injury Report

Child's Name:

Date of Injury: __ /__ /__

When did the injury happen? ________________________________________________

Location where injury occurred ______________________________________________

Equipment or product (For example, chair / glue) involved ____________________________

Description of injury or which parts of the body were injured? _________________________

How did the injury happen? ________________________________________________

Who gave first aid and what they did: _________________________________________

Where else did the child receive treatment and what was done:
(Specify clinic, office or emergency room; did the child require a doctor's or dentist's treatment.) _______________________________________

Follow-up plan for care of the child __________________________________________