Sample CNC Accident Report Form

SUPPORTING DOCUMENTS
Sample CNC Accident Report Form
Name of CNC Site:
Type of Care: ☐ Long Term
☐ Short Term
☐ Combined Care
Child’s Name:
Parent’s Name:
Date of Accident:
Time of Accident:
Describe the injury:
Describe How the Accident Occurred:
Was First Aid given?
☐ Yes
☐ No
Additional comments:
Witness’s name:
Signature:
CNC Staff completing this form:
Signature of CNC Staff:
I have been informed of this accident
Date:
☐ Yes
☐ No
Parent’s Name:
Parent’s Signature:
Date:
February 2016
17 Fairmeadow Avenue, Suite 211, Toronto, ON M2P 1W6 — Tel. 416.395.5027 | Fax. 416.395.5190 | www.cmascanada.ca
Funded by: Immigration, Refugees and Citizenship Canada / Financé par: Immigration, Réfugiés et Citoyenneté Canada
Supporting Child Care in the Settlement Community / Soutenir les services de garde d’enfants dans la communauté d’accueil