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.
*Name of facility/provider:
*Date of incident:
*Time of incident:
*Type of injury/incident:
Check all that apply
Body Part(s) Affected:
Who transported child (if applicable):
Please give a brief summary of the incident:
Name of Person Completing Form: