DATE________

            DEAR________

            TODAY AT DAYCARE I HAD A SMALL ACCIDENT!

            WHEN DID IT HAPPEN?
            ____________________________________________.

            WHAT HAPPENED?
            _____________________________________________________________________.

            HOW DID IT HAPPEN?
            _____________________________________________________________________.

            WHAT ACTION WAS TAKEN?
            _____________________________________________________________________.

            WAS MEDICAL ATTENTION NECESSARY?
            YES_____
            NO _____

            IF SO, What action was taken
            _____________________________________________________________________.

            SIGNATURE OF PARENT______________________________________
            SIGNATURE OF PROVIDER____________________________________

            ~form courtesy Debbie from Oklahoma, Little Ones Child Development Home