EarlyON Serious Occurence Report

Contact Information

* Name

* Position

* Phone xxx-xxx-xxxx

* Email

EarlyON Centre Information

* Centre

* Address

* City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

* Postal Code

Incident Information

* Date of Incident

* Time of Incident HH 123456789101112 : MM 00 15 30 45 a.m. p.m.

* Date Aware of Incident

* Time Aware of Incident HH 123456789101112 : MM 00 15 30 45 a.m. p.m.

* If it has been longer than 24 hours, explain why

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* Type of Incident

• Death of a child or caregiver that occurs on the premises
• Abuse, neglect or an allegation of abuse or neglect of a child
• Life-threatening injury to a child or caregiver or life-threatening illness of a child
• An incident where a child goes missing from the EarlyON location
• An unplanned disruption of the normal operations of a child and family centre premises that poses a risk to the health, safety or well-being of children attending the centre
• Fire
• Flood
• Gas leak
• Detection of carbon monoxide
• Outbreak
• Lockdown
• Other, specify
• A situation with high potential for public criticism of the Service Agency, Niagara Region, Ministry or if the situation may lead to questions being asked by the media

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Describe the Incident
Do not use names, ages or date of birth

* What happened?

* Where and when did the incident occur?

* Action(s) Taken

* Action(s) proposed to Minimize Reoccurrence

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* Who has been notified (specify in Actions Taken above)?

• Police
• Family and Children's Services
• Parent / Guardian / Emergency Contact
• Other, specify:

Notice of Collection

Any personal information or personal health information submitted will be collected, used, and disclosed, where applicable, by members of Regional staff according to the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act. Any information you share will only be used for the intended purpose for which it was provided.

For questions or comments about privacy practices, or for more information about the administration of the Municipal Freedom of Information and Protection of Privacy Act in Niagara Region programs, see Freedom of Information and Open Government.