Childcare Emergency Procedures Checklist Form
Use this form to document emergency readiness, checklist completion, incident response, and follow-up for childcare situations.
Child Information and Emergency Contacts
Child's Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Date
Classroom / Group
*
Please Select
Infants
Toddlers
Preschool
Pre-K
Kindergarten
School Age
Other
Parent / Guardian Name
*
First Name
Middle Name
Last Name
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Emergency Contact Name
*
First Name
Middle Name
Last Name
Secondary Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Pickup Person(s)
*
Allergy / Medical Alert Notes
Emergency Procedure Checklist
Emergency type
*
Injury
Fire
Severe weather
Missing child
Lockdown
Allergic reaction
Other
Confirm child location and safety
*
Child is located and safe
Child location is still being verified
Account for all children
*
All children are accounted for
One or more children are unaccounted for
Contact parent or guardian
Parent or guardian has been contacted
Parent or guardian contact is still needed
Notify director or lead staff
Director or lead staff has been notified
Director or lead staff has not yet been notified
Call emergency services if needed
Emergency services have been called
Emergency services are not needed at this time
Procedure-specific notes
Emergency kit prepared
Evacuation steps followed
Shelter-in-place steps followed
Additional notes required
Incident Response and Follow-Up
Incident Date and Time
*
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Staff Member Completing Form
*
First Name
Middle Name
Last Name
Actions Taken
*
Were Emergency Services Contacted?
*
Yes
No
Parent or Guardian Notified?
*
Yes
No
Attempted, No Contact
Not Required
Follow-Up Needed?
*
Yes
No
Submit
Should be Empty: