Unlicensed Childcare Incident Report
Report an incident involving unlicensed childcare with the date, location, people involved, what happened, and any immediate actions taken.
Incident Details
Incident Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Time
*
Hour Minutes
AM
PM
AM/PM Option
Incident Location
*
Incident Address
Please Select
Option 1
Option 2
Option 3
Incident Type
*
Supervision Issue
Safety Concern
Injury
Missing Child
Unauthorized Pickup
Unsafe Environment
Other
Child and Caregiver Information
Child’s Name
*
First Name
Last Name
Child’s Age
*
Caregiver/Parent Name
*
First Name
Last Name
Caregiver Contact Information
*
Incident Description and Follow-Up
Detailed Incident Description
*
Immediate Actions Taken
*
Witnesses or Others Involved
Preferred Follow-Up Method
*
Phone call
Email
Written update
No follow-up
Submit report
Should be Empty: