Student Accident/Injury Report STUDENT LOCATION (SCHOOL AND SITE #) DATE REPORTED DATE OF INCIDENT DATE OF BIRTH GRADE PHONE STUDENT ADDRESS DID YOU WITNESS PARENT NOTIFIED YES____ NO____ LOCATION OF INCIDENT BY WHOM: INCIDENT YES____ NO____ (NAME AND POSITION) PARENT COMMENTS: LOSS OF BLOOD WAS STUDENT TREATED BY A MEDICAL PROFESSIONAL YES____ NO___ Time of Day_________ YES____ NO____ IF YES: SCHOOL NURSE______________________________ Sport, MEDICAL DOCTOR/FACILITY__________________________ if any_____________ Area Of Injury Type of Incident Cut Head Neck Struck Against Bruise/Scrape Face Back Struck By Puncture Eye Right Left Chest Caught Between Foreign Body Ear Abdomen Trip & Fall Broken Teeth / Mouth Groin Slip & Fall Dislocated Shoulder Right Left Hip Right Left Trip or Slip Burn Arm(Upper) Thigh Overexertion Strain / Sprain Elbow Knee Inhale / Swallow Forearm Leg Heat / Electricity / Flash Amputation Wrist Ankle Chemical*(IDENTIFY Below) Rupture Hand Foot Other Toe Other Finger/Thumb Where and How Did Incident Happen? (BE SPECIFIC AND MAY INCLUDE FURTHER DESCRIPTION OF INJURY) What were the instructions given by the parent or guardian: Who was in charge when accident occurred: (name and position) Witnesses involved, if any: Describe what action was immediately taken: Employee Employee Date Signature (Print) Signature Supervisor Supervisor Date Name (Print) Signature
Student Accident/Injury Report STUDENT LOCATION (SCHOOL AND SITE #) DATE REPORTED DATE OF INCIDENT DATE OF BIRTH GRADE PHONE STUDENT ADDRESS DID YOU WITNESS INCIDENT YES____ NO____ PARENT NOTIFIED YES____ NO____ BY WHOM: (NAME AND POSITION) PARENT COMMENTS: LOCATION OF INCIDENT LOSS OF BLOOD YES____ NO____ WAS STUDENT TREATED BY A MEDICAL PROFESSIONAL YES____ NO___ IF YES: SCHOOL NURSE______________________________ MEDICAL DOCTOR/FACILITY__________________________ Time of Day_________ Sport, if any_____________ Area Of Injury Type of Incident Cut Head Neck Struck Against Bruise/Scrape Face Back Struck By Puncture Eye Right Left Chest Caught Between Foreign Body Ear Abdomen Trip & Fall Broken Teeth / Mouth Groin Slip & Fall Dislocated Shoulder Right Left Hip Right Left Trip or Slip Burn Arm(Upper) Thigh Overexertion Strain / Sprain Elbow Knee Inhale / Swallow Forearm Leg Heat / Electricity / Flash Amputation Wrist Ankle Chemical*(IDENTIFY Below) Rupture Hand Foot Other Finger/Thumb Toe Other Where and How Did Incident Happen? (BE SPECIFIC AND MAY INCLUDE FURTHER DESCRIPTION OF INJURY) What were the instructions given by the parent or guardian: Who was in charge when accident occurred: (name and position) Witnesses involved, if any: Describe what action was immediately taken: Employee Signature (Print) Employee Signature Date Supervisor Name (Print) Supervisor Signature Date