How to Complete the Serious Occurrence Notification Form

accident reportProgram Name:

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


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

Date of Occurrence:

Provide the date that the serious occurrence happened.


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


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.


  • 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.


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

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