Child care providers are required to report a child death or serious injury within 24 hours of the incident.
You can make a report by filling out the form below.
Incidents that require a report include, but are not limited to:
• The death of a child if the child died while in your care.
• A serious injury that results in the child getting professional medical treatment while in your care.
• The death of a child you care for if the child died of a contagious disease.
Serious Injury Death (Please Select).
    Please type "N/A" if information is not available.
  Date of Incident   (mm/dd/yyyy)
  Time of Incident   (hh:mm AM/PM)
Name Of Provider
  Phone Number
  Child First Name
  Child Last Name
Child DOB  (mm/dd/yyyy)
Child SEX   (M/F)
  Child DCN *   * If no DCN enter 00000000
  Parent First Name
  Parent Last Name