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Head Start Incident Report
Type of Incident
Accident
Behavior
Concern
Bravo (Noteworthy things)
Your Name:
Your Email:
Center:
Beaver
Cedar 1
Cedar 2
Cedar 3
Cedar 4
Cedar 5
Delta
Dixie 1
Dixie 2
Enoch
Escalante
Fillmore
Hurricane 1
Hurricane 2
Hurricane 3
Kanab
Milford
Panguitch
Parowan
St. George 1
St. Geroge 2
St. George 3
St. George 4
St. George 5
St. George 6
Other
Date of Incident:
Approximate Time of Incident:
Child Involved:
Child's Birth Date (mm/dd/yyyy):
Name of Parent or Guardian Notified:
Name of person in the Central Office Notified:
Description of the Incident: (who, what, where, when and what did you do?)
DECA Strategies Implemented:
For accident reports, identify what can be done to prevent similar incidents:
Bodily fluid clean-up procedure used:
Email address(es) of those to whom you would like to send copies of your report (comma delimited)
