EarlyOn Serious Occurrence Report

EarlyOn address:

Email address

Incident information

Incident reported by:

First name:

Last name:

Position:

Date of incident:

Time of incident:

Age group:

Date you became aware of the serious occurrence:

Same as date of incident:

Yes

No

Time you became aware of the serious occurrence:

Same as time of incident:

Yes

No

Please explain if more than 24 hours have passed since the date/time you became aware of the serious occurrence:

Child information

Were all children in the program/age group involved in or impacted by the occurrence:

Yes

No

Serious occurrence information

Type of serious occurrence:

Please describe what happened, where the serious occurrence took place, and the actions taken by the licensee (do not use names, ages or dates of birth).

Who has been notified?

Parent/guardian/emergency contact

Emergency services

CMSM/DSS

Children's Aid Society

Public Health

Other

Are police conducting an investgation?

Yes

No

Has there been media attention?

Yes

No

Is the Children's Aid Society conducting an investigation?

Yes

No

Further action proposed by licensee:

Is this expected to be the only/last report submitted for this occurrence?

Yes

No

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EarlyOn Serious Occurrence Report

Incident information

Child information

Serious occurrence information