Program Name:

Provide the name of the child care centre or private-home day care agency.

Date:

Provide the date that the Serious Occurrence Notification Form is posted on site.

Date of Occurrence:

Provide the date that the serious occurrence happened.

Type:

Provide the type of serious occurrence, according to the definitions set out in the MCSS / MCYS 2009 Serious Occurrence Reporting Procedures. The operator uses one of the following terms:

• Death of a child
• Serious injury caused by service provider
• Serious injury – accidental
• Serious injury – self-inflicted/unexplained
• Alleged abuse/mistreatment
• Missing child
• Disaster on the premises
• Complaint about service standard
• Other – complaint made by or about a child, or any other serious occurrence

Description:

Provide a one sentence description of the occurrence. (Sample wording for illustration purposes only, not intended as a comprehensive list):

Serious injury caused by service provider:

• A child was injured when a staff tripped on the playground and knocked over the child.

Serious injury – accidental:

• A child was injured while running in the playground.

Serious injury – self-inflicted/unexplained:

• A child was limping after outdoor playground play – no injury was observed.
• A staff member was alleged to have abused a child while participating in the child care program.

Missing child:

• A child was left on the playground unsupervised at the end of outdoor play.
• A child left the centre and was found later at home.
• A child walked to a friend’s home after school. The parent and the centre did not know the child’s whereabouts for one hour.

Disaster on the premises:

• Smoke was observed coming from the furnace room.
• Complaint about service standard:
• A parent complained that not enough food is served at lunch.

Other – complaint made by or about a child, or any other serious occurrence:

• A parent complained that another child bullies their child.

Note: physical restraint is not permitted in child care reportable child care serious occurrence category.

Action Taken by Operator / Outcome: (add update if applicable)

Provide a description of the action taken by the operator. This section will include the operator’s longer term plans and additional outcomes to minimize recurrence of the occurrence, e.g. behaviour management training.

Examples:

• The operator sought medical attention for the child’s injury.
• The child was transported to hospital by ambulance, treated and released that day.
• Behaviour management monitoring will be conducted each month.

If an update is made to add additional actions taken/outcomes, the operator will indicate the date of the update.

Signature:

The operator or designate (e.g. the child care centre supervisor) signs the Serious Occurrence Notification Form.