OCFS-LDSS-7019
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
Illness, Injury & Indicators of Abuse Log
| |You can use this form or you can create your own master form using this as a guide. |
|Maintain |It is required that a daily health check be conducted and recorded for each child. |
|On-Site |Symptoms of illness include but are not limited to: wheezing, coughing, runny nose, change in appetite, crying, pulling of ears, wetting of clothes, etc. |
| |Suspicions of child abuse/neglect may include but are not limited to: unexplained bruises, injuries; burns; swelling, itching, bleeding, cuts in genital or anal areas, lack of medical |
| |care/attention, malnutrion, etc. |
|As a child care provider you are required to report serious incidents and injuries to the OCFS Regional Office or your Registrar. |
|As a mandated reporter of child abuse and maltreatment, you are required to report suspected child abuse to the child abuse hotline at 1-800-635-1522. |
|PROVIDER/FACILITY NAME: | |CHILD’S NAME: |
| | | |
|FACILITY ID NUMBER: |FACILITY TELEPHONE NUMBER: | |CHILD’S DATE OF BIRTH: |
| | | | / / |
|OBSERVATION/ASSESSMENT |
|DATE |TIME |SYMPTOMS OF ILLNESS/ DESCRIPTION OF |OR |SUSPICIONS OF ABUSE/ NEGLECT |ACTIONS TAKEN |CHILD DISMISSED|NAME AND INITIALS OF PERSON |
| | |INJURY | | | | |REPORTING ILLNESS/INJURY/ABUSE|
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
(Continued on reverse side)
NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
Illness, Injury & Indicators of Abuse Log (continued)
|PROVIDER/FACILITY NAME: | |CHILD’S NAME: |
| | | |
|FACILITY ID NUMBER: |FACILITY TELEPHONE NUMBER: | |CHILD’S DATE OF BIRTH: |
| | | | / / |
|OBSERVATION/ASSESSMENT |
|DATE |TIME |SYMPTOMS OF ILLNESS/ DESCRIPTION OF |OR |SUSPICIONS OF ABUSE/ NEGLECT |ACTIONS TAKEN |CHILD DISMISSED|NAME AND INITIALS OF PERSON |
| | |INJURY | | | | |REPORTING ILLNESS/INJURY/ABUSE|
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
| / / | : | AM | | | | YES |PRINT YOUR NAME |
| | |PM | | | |NO | |
| | | | | | | |INITIAL HERE |
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