MLEDP Incident Report FormBasic Information Center Name - Select -MLEDP at Foster, 700 Vermont Ave. Pgh, PA 15234MLEDP at Hoover/Hoover KC, 37 Robb Hollow Rd. Pgh, PA 15243MLEDP at Howe/Howe KC, 400 Broadmoor Ave. Pgh,PA 15228MLEDP at Jefferson, 11 Moffett St. Pgh, PA 15243MLEDP at Lincoln/Lincoln KC, 2 Ralston Pl. Pgh, PA 15216MLEDP at Markham, 165 Crecent Dr. Pgh, PA 15228MLEDP at Washington, 735 Washington Rd. Pgh, PA 15228MLEDP Summer Name of Child Child's Address Child's Sex Male Female Child's Date of Birth Name of Parent Parent's Email This form was sent to the email address above on the date listed below and a copy will be added to your child's file. Parent's Address Parent's Phone Number Parent Notified By (Staff Member): Time Parent Was Notified Description of Incident Date and Time of Incident Date and Time of Incident: Date Date and Time of Incident: Time Location Incident took place (ex: Cafeteria, Gym, Blacktop, Etc..) Equipment/Product Involved: Type Of Injury Part of Body Injured Cause of InjuryAction Taken First Aid Given by Center Staff Was a Local Authority Notified of the Incident - Select -YesNoThe Following 6 questions regarding the Local Authority and Care Provider are only required if you answered "YES" to the question above. If you answered "NO", please skip to the field marked "Required Follow Up" Name of Local Authority Address of Local Authority Phone Number of Local Authority Treatment Provided By: Address of Treatment Provider Phone Number of Treatment Provider Nature of Treatment Required follow Up Signature of Staff Member Completing This Report Sign above Name of Staff Member Completing This Report Title of Staff Member Completing this Report Date Form Completed Did the incident result in inpatient hospitalization, emergency room treatment, services of a fire company, or the death of a child receiving care at the facility - Select -NoYes, and I will notify the Regional Day Care Office within 24 hours by phone: 412-565-5183 and 72 hours by Fax: 412-565-2658 Leave this field blank