SOP: Reporting Head Injuries in Child Care

For Administrative Staff

Purpose:
To ensure every head injury is handled immediately, documented accurately, communicated to families, and reported to licensing when required.

Licensing states that child care providers must have a written plan for reporting and managing incidents that threaten the health, safety, or welfare of a child. DCF also lists injuries or illness requiring hospitalization or emergency treatment as reportable emergency events.

Head Injury Procedure

1. Immediate Safety Response

When a child sustains any injury to the head, face, eye, mouth, or neck area, staff must immediately notify the Director, Assistant Director, or designated administrator.

The administrator must:

Go to the child immediately.
Assess the child calmly.
Remove the child from any unsafe area.
Keep the child under direct supervision.
Do not move the child if there is concern about neck, spine, loss of consciousness, seizure, or serious trauma.
Call 911 immediately if emergency symptoms are present.

2. Call 911 Immediately If Any of These Symptoms Are Present

Call 911 before calling the parent if the child has:

Loss of consciousness, even briefly.
Seizure.
Repeated vomiting.
Trouble breathing.
Severe headache or inconsolable crying.
Confusion, extreme sleepiness, or unusual behavior.
Unequal pupils.
Blood or fluid from the nose or ears.
Large bump, deep cut, heavy bleeding, or suspected fracture.
Injury caused by a fall from height.
Any concern that the child needs emergency medical care.

After 911 is called, contact the parent/guardian immediately.

3. Parent Notification

For any head injury, even if it appears minor, the parent or guardian should be contacted as soon as possible.

Use calm, factual language:

“I am calling to inform you that [child’s name] bumped their head at [time] while [brief factual description]. We checked the child immediately. At this time, we observed [symptoms/no symptoms]. We are continuing to monitor and will complete an incident report for you to review and sign at pickup.”

Avoid saying:

“They are fine.”
“It was nothing.”
“There is no need to worry.”
“The teacher didn’t see anything.”
“It was another child’s fault.”

Instead say:

“At this time, these are the symptoms we observed…”

4. Monitor the Child

Until the parent arrives or the child returns to normal activity, administrative staff must ensure the child is monitored for:

Vomiting.
Drowsiness.
Changes in behavior.
Dizziness.
Complaints of pain.
Bleeding or swelling.
Difficulty walking or balancing.
Changes in speech, crying, or alertness.

Document the time of each observation.

Example:

10:15 AM — Child alert, sitting with teacher, no vomiting observed.
10:30 AM — Child playing quietly, bump visible on forehead, parent notified.

5. Complete the Incident Report the Same Day

The report must be completed before the end of the day and shared with the parent/guardian or authorized pickup person.

Include:

Child’s full name.
Date and exact time of incident.
Location of incident.
Staff present.
What happened, using facts only.
What part of the head/body was injured.
Visible symptoms or marks.
First aid provided.
Time parent was contacted.
Name of person contacted.
Whether 911 was called.
Follow-up observations.
Staff signature.
Administrator signature.
Parent/guardian or authorized pickup signature.

DCF provides an Accident/Incident Report sample form on its child care forms page.

6. Report to Licensing When Required

The Director or designated administrator must notify the licensing authority if the injury:

Requires emergency medical treatment.
Requires hospitalization.
Results in serious injury.
Involves suspected abuse, neglect, lack of supervision, or unsafe conditions.
Involves an incident that threatens the health, safety, or welfare of a child.

Florida DCF specifically identifies injuries or illness requiring hospitalization or emergency treatment as emergency events.

If abuse or neglect is suspected, report to the Florida Abuse Hotline at 1-800-962-2873 or through the official online reporting tool. Florida DCF states that abuse, neglect, or exploitation reports should not be submitted through the child care complaint form and must be reported through the Abuse Hotline/reporting system.

7. Internal Administrative Review

The Director must review every head injury report within 24 hours.

Review:

Was the child properly supervised?
Was ratio maintained?
Was the environment safe?
Was parent notification timely?
Was documentation complete?
Is additional staff training needed?
Does the classroom, playground, furniture, or equipment need correction?

If a hazard caused or contributed to the injury, remove children from the area until corrected.

8. Documentation Storage

Keep the signed incident report in the child’s file according to licensing and company record-retention requirements. Maintain a copy in the administrative incident log.

Do not alter the report after parent signature. If additional information is needed, complete an addendum with the date, time, and signature of the person adding the information.

Staff Script for Parent Call

“Hello, this is [name] from [school]. I’m calling to inform you that [child’s name] had a head injury today at [time]. [Briefly explain what happened factually.] We checked the child immediately and observed [describe symptoms or no visible symptoms]. We are monitoring closely and will complete an incident report for you to review and sign. We will call you immediately if anything changes.”

If emergency care is needed:

“We have called 911 because [child’s name] is showing symptoms that require emergency medical attention. We are with your child now and will keep you updated.”

Staff Reminder

All head injuries must be treated seriously, even when they appear minor. The school’s responsibility is to respond immediately, observe carefully, communicate transparently, document accurately, and report when required.