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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