Use this form to notify the department of the occurrence of an injury of a child under the supervision of a center/provider that requires outside medical treatment (IROMT) or a death of a child. Completion of the reporting form will be helpful in gathering statistics for all child care programs in Virginia.
Please complete and submit this online form as soon as practicable but not to exceed two (2) business days of an occurrence of an IROMT or one (1) business day of a death of a child in care.
*This form is intended to be completed only by child care providers.
**Please refer to your program's applicable standards/laws for any additional regulatory requirements regarding reporting injuries or the death of a child in care.
*Name of facility/provider:
*Date of incident:
*Time of incident:
*Type of injury/incident:
Check all that apply
Body Part(s) Affected:
Who transported child (if applicable):
Please give a brief summary of the incident:
Name of Person Completing Form: