Ocfs.ny.gov
OCFS-4436 (5/2014) FRONT NEW YORK STATE
OFFICE OF CHILDREN AND FAMILY SERVICES
INCIDENT REPORT FOR CHILD DAY CARE
INSTRUCTIONS
• This form may be used to maintain a record of illnesses or injuries of a child while in care.
• This form may be used to notify parents of illnesses or injuries occurring with their children while in care.
• Please PRINT clearly and attach additional sheets if needed.
• If death of a child occurs, you must immediately notify the Office of Children and Family Services Regional Office at 1-800-732-5207.
|Today’s Date: | |License/Registration Number: | |
|Program Name: | |
|Name of Child: | |DOB: | |
| | (Please print full first and last name) |
|Details of Incident (Include date, time and location where incident occurred) (Due to confidentiality, the names of other children involved in any incident may |
|not be shared with parent(s)) |
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|Injuries (Include a full description of any and all marks, bruises & abrasions) |
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|Medical Services/Treatment Provided (Please include any and all treatment, listing who administered treatment) |
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(Continued on reverse)
OCFS-4436 (5/2014) REVERSE
Caregiver(s)
|Name: | |Date: | |
| |(Signature) | | |
|Name: | |Date: | |
| |(Signature) | | |
Witnesses to the Incident
|Name: | |Date: | |
| |(Signature) | | |
|Name: | |Date: | |
| |(Signature) | | |
Parent/Guardian Notified
|Name: | |Date: | |
| |(Signature) | | |
|Name: | |Date: | |
| |(Signature) | | |
Office of Children & Family Services Notified By
|Name: | |Date: | |
| |(Signature) | | |
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