DAY CARE ACCIDENT REPORT FORM

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DAY CARE ACCIDENT/INCIDENT REPORT FORM
The Department of Human Services requires that McLeod County Daycare Licensing be notified,
within 24 hours, of an accident or incident requiring medical or dental care. Send this form to your
day care licensing worker immediately, and call the licensor at (320) 864-3144.
(9502.0375, Subp. 1D)
Provider’s Name ___________________________________ Phone Number ___________________
Address __________________________________________ City ________________ Zip ________
Date of Report: ___________________
Date of Accident/Incident: __________________
Time of Accident/Incident: _________________
Date daycare was notified, by parent, of medical or dental care needed: _______________________
Child’s Name ________________________________________ Age of the Child _______________
Parent’s Name _______________________________________ Phone Number ________________
Address _________________________________________ City ________________ Zip _________
Place of Accident/Incident: __________________________________________________________
________________________________________________________________________________
Nature of Injury Received: ___________________________________________________________
________________________________________________________________________________
Describe how Injury/Accident/Incident Occurred: _________________________________________
________________________________________________________________________________
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Action Taken: _____________________________________________________________________
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______________________________________
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Signature of Parent
Date
______________________________________
_________________________________
Signature of Daycare Provider
Date
Send form to: McLeod County Daycare Licensing, McLeod
Health & Human Services Building, 1805 Ford Avenue N, Suite 100, Glencoe, MN 55336
(Please give 1 copy to the parent, and keep 1 copy for your file.)
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