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Injury of a Child Requiring Outside Medical Treatment/Death Report (IROMT) - Subsidy

Report to VDSS - Injury of a Child Requiring Outside Medical Treatment or Death For Subsidy Approved Vendors

This form is to be used by Subsidy Approved Vendors to meet the mandatory requirement to notify the department of the occurrence of an Injury Requiring Outside Medical Treatment (IROMT)* or death of a child.

*For the purposes of this reporting form only: Serious Injury means an injury of a child while under the care of a center/provider that requires outside medical treatment.


Please complete and submit this form as soon as practicable but not to exceed two (2) business days of an occurrence of a serious injury or one (1) business day of a death of a child in care.

*This form is intended to be completed only by child care providers.

**Please refer to your program's applicable standards/laws for any additional regulatory requirements regarding reporting injuries or the death of a child in care.

Online Report

Licensed Provider?:

Vendor ID#:

*Name of facility/provider:





* :

*Type of injury/incident:
Check all that apply

Body Part(s) Affected:

Where did injury occur?

Medical Treatment Given/Action Taken

Who transported child (if applicable):

Please give a brief summary of the incident:

Name of Person Completing Form:

Title:   Date: