Oregon Department of Early Learning and Care • Child Care Licensing Division • www.oregon.gov/delc • PR-0210 (4/2024)
Incident Report Form
This form is not required by the Child Care Licensing Division (CCLD) but could be used to document the
following types of incidents:
• Behavioral concern
• Lost or unattended child
• Mandatory reporter incident
• Animal bite (in addition to a possible injury report)
Child’s Information
Child’s Name: Child’s Age:
Details and Description of Incident
Date and Time of Incident:
Where did the incident occur? Classroom Bathroom Bus/Vehicle
Hallway
Kitchen
Playground
Other:
Who was supervising the child at the time of incident?
Any other adult witnesses?
Yes No If yes, list names:
Description of Incident:
Description of action taken:
Procedural or staffing changes made as a result of this incident: N/A
Follow-Up Action Taken
Child treated and remained at child care Child taken home Called 911
Mandatory report made Other:
Notifications (as required by rule):
Parent Name: Notified by:
Note
Phone in Person
DHS Name: Date: N/A
Law Enforcement Name: Date: N/A
CCLD Name: Date: N/A
Teacher’s Signature: _____________________________________________________ Date: ___________________
Parent’s Signature: ______________________________________________________ Date: ___________________
