Injury Report Form
Child’s Name _____Jimmy Burnside__________________________ Date: 2/09/2011_______________________
Comments: ____This is a very serious injury. And should be given attention immediately._________________________________________________________
Description of Injury ___ Jimmy’s Injury consists of what appears to be a large burn approximately two inches long by one inch wide on his Buttocks .This potential burn was lined on one side of the injury by several small bruises.___________________________________________________
Location and Size of injury __________Buttocks; Two inches long by one inch wide_______________________________________
Description of Child’s Behavior______Jimmy sectioned himself off from the class. He also gave me a hard time getting him to the table for snack. As he tried to sit tears began to roll down his face.________________________________________________________
Additional Comments / Concerns: _Needs Attention A.S.A.P.___________________________________________
Reported by: Syatonia Isom_________________________________________________
1. Teachers and Caregivers, Center Director or principals, Health care providers (Doctors and Dentists), Social workers, Clergy, etc.
2. This law is an Act to Provide Financial Assistance for a Demonstration Program for the Prevention, Identification, and Treatment of Child Abuse and Neglect, to establish a National Center on Child Abuse and Neglect and for Other Purposes.
* Physical abuse (Beating, slapping, or hitting. Pushing, shaking, kicking, or throwing. Pinching, biting, choking, or hair-pulling. Burning with cigarettes, scalding water, or other hot objects.)
* Sexual abuse (Fondling - Touching or kissing a child's genitals, making a child fondle an adult's genitals. Violations of bodily privacy - Forcing a child to undress, spying on a child in the bathroom or bedroom. Exposing children to adult sexuality...