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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
Delta
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
Washington 1
Washington 2
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?)
For accident reports, identify what can be done to prevent similar incidents:
Bodily fluid clean-up procedure used:
Would you like to be contacted to staff this child at an OPTIONS staffing meeting?
Yes
Email address(es) of those to whom you would like to send copies of your report (comma delimited)
