EmailMe Form - Accident/ Incident/ Issues Reporting Form:

Your Name (Babysitter): *

First Last

Your Preferred Contact Email Address: *

Date and Time of the accident/incident/issue: *

DD / MM / YYYY HH : MM AM/PM

Be as accurate as possible (and as applicable to the type of incident).

Location of accident/incident/issue: *

Where did this accident/incident/issue occur? (Families home, school, preschool, out and about etc.).

Names of others involved: *

Name all people that were involved/present at the time:

Please describe in detail what happened: *

Please tell us in a narrative style anything that happened prior to the specific event/issue and the details of the event.

Immediate Action Taken by You: *

Please describe any conversations or actions you have taken in relation to this event.

Do you require us to contact you further regarding this event?: *

Do you believe we need to contact the family further regarding this event?: *

How would you like us to follow up with you (the babysitter) or the family with regards to this event?: *

Further Comments/Recommendations: *

If you believe there was a clear cause for the event or have any recommendations as to prevent such events in the future please outline them here.

Date and Time this form was completed: *

DD / MM / YYYY HH : MM AM/PM

You (as named below), agree that all the information provided by you on this form above is accurate, and truthful to the best of your knowledge at the time and date identified immediately above. *

Yes I agree

Type Your Name (in lieu of a signature): *

First Last