Student Accident/Injury Report

Student Information

First Name*

Answer required for "First Name"

Last Name*

Answer required for "Last Name"

Grade*

Answer required for "Grade"

Date of Injury*

Answer required for "Date of Injury"

Time of Injury*

Answer required for "Time of Injury"

Supervised Activity?*

Answer required for "Supervised Activity?"

Yes

Athletic Activity*

Answer required for "Athletic Activity"

Yes

If yes, please list sport

Answer required for "If yes, please list sport"

Side of body injured (required for claim form)*

Answer required for "Side of body injured (required for claim form)"

Right

Left

Not Applicable (I will put identifying information in the description below)

Describe Incident (How did it happen and what is the actual injury ie. cut, bruise, twisted ankle, etc.)*

Answer required for "Describe Incident (How did it happen and what is the actual injury ie. cut, bruise, twisted ankle, etc.)"

Were parents/guardians notified?*

Answer required for "Were parents/guardians notified?"

Yes

Was student taken to a doctor/hospital?*

Answer required for "Was student taken to a doctor/hospital?"

Yes

If yes, how and by whom?

Answer required for "If yes, how and by whom?"

If taken by school employee or ambulance, name of doctor/hospital

Answer required for "If taken by school employee or ambulance, name of doctor/hospital"

Name of person filling out this form*

Answer required for "Name of person filling out this form"

Email address of person filling out this form*

Answer required for "Email address of person filling out this form"

Please fix the highlighted areas below before submitting.