Creative Kids Place - Incident Report

Incident Report

Location: *

Mississauga West Streetsville Square One Churchill Meadows Port Credit Oakville Oakville West

Date & Time of Incident *

Date Report Written: *

Report Written By

First name *

Last name *

Report Reviewed and Approved by (Name & position)

Type of Report *

Injury Behaviour Near Miss Other

Other

Category of Report *

Major Critical Serious Minor Very Low

Child Involved

Child's Full Name *

Child's Age

Child's Gender *

Male Female Other

The Incident

Time of Incident

Specific Location of Incident

Equipment involved in the incident (such as toys, playground equipment, furniture, medication)

Please provide details on how the incident happened (include any special or unusual circumstances related to the incident): *

Cause of Injury

Specific Cause of the Injury *

Fall from a Height Pinched/Caught In Burn Sharp/Piercing Object Hit By or Bumped Into an Object Human Bite Splinter/Foreign Object Other

Other

Type of Injury *

Body Parts Injured *

Witness #1 to the Incident

First name

Last name

Mobile

Position at CKP

Witness #2 to the Incident

First name

Last name

Mobile

Position at CKP

Were Parents/Guardians Notified? *

Yes No

When Were Parents/Guardians Notified?

How Were Parents Notified?

Phone Voicemail Email In Person