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Incident/Injury Report (JFS 01299)

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Ohio Department of Children and Youth

INCIDENT/INJURY REPORT FOR CHILD CARE

Type of program
SECTION I
Is this a child who has a written medical/physical care plan on file as defined in the Ohio Administrative Code?(If yes, explain in summary section)
Sex of child
At the time of the incident/injury/illness
Were parents contacted?
How many hours is this child in your care per day? (check one)
Age of child-group that child was assigned to at the time of the incident/injury/illness
SECTION II
TYPE OF INJURY (check all that apply)
BODY PART AFFECTED (check all that apply)
TYPE OF ILLNESS (check all that apply)
TYPE OF INCIDENT (check all that apply)
WHERE DID INCIDENT/INJURY HAPPEN? (check all that apply)
INCIDENT HAPPENED DURING?
ACTION TAKEN (check all that apply)
Signature of Person Completing Form
JFS 01299 (Rev. 4/2024)Page 1 of 2

Incident/Injury Report Instructions

A JFS 01299 "Incident/Injury Report" must be completed when:

  • A child becomes ill or receives an injury which requires any first aid treatment.

FILL IN REQUIRED SECTION I ON THE FRONT SIDE OF THIS FORM. Provide a complete description of the incident/injury/illness in the summary section (if additional space is needed, attach paper to the incident report). The person completing the form signs the report and it is provided on the same day of the incident to the parent/guardian or person picking up the child from the center/home. Request parent/guardian/caregiver to sign report; however, do not delay giving report to parent if parent refuses to sign. The parent's signature is not required. PLEASE BE SURE ALL SECTIONS HAVE BEEN COMPLETED.

DEFINITIONS

Incident:
An unusual event that happens that does not necessarily result in an injury to the child. A copy of the report for an incident shall be retained on file at the center or home for at least one year and shall be available for review by the Ohio Department of Children and Youth or county agency.
Minor Injury:
An injury resulting in a child being able to return to normal activity; basic first aid may be given by staff. A copy of the report for a minor injury shall be retained on file at the center or home for at least one year and shall be available for review by the Ohio Department of Children and Youth or county agency.

Child care providers may contact the Family and Customer Support Center toll-free at (877) 302 2347 Option 4, for technical assistance.

JFS 01299 (Rev. 4/2024)Page 2 of 2