Skip to main content
Santa Ynez Valley Union High School District
Main Menu Toggle
About
Our Mission
Board of Education
Calendars
LCAP
Strategic Plan
Governance
Agendas & Minutes
Board Members
Board Policies
Governance Handbook
Public Notices
Schools
Santa Ynez High School
Refugio High School
Documents
Academic Calendar
By-Trustee Area Elections
COVID-19 Resources
CUPCCAA Registration
Discipline Policy & Procedures/Annual Notifications
Interdistrict Transfer
Expanded Learning Opportunities Grant Plan
LCAP (Local Control Accountability Plan)
Learning Continuity Plan (LCP) 2020-2021
Public Notice Child Find
School Accountability Report Card
Strategic Plan
TITLE IX Required Notices
Uniform Complaint Procedure Form
Williams Uniform Complaint Procedures Form
Exam
Departments
Business Services
Information Technology
Personnel Services
Facilities/Operations Department
Office of Superintendent
Solicitations for Bids
Nutrition Services
Menu
Measure K Projects
Bond Oversight Committee
Committee Members
Measure K Project List
Agenda and Meetings
Monthly Expenditure Reports
Annual Expenditure Reports
Key Analytics
Contact
SYVUHSD Facebook
Staff Directory
Public Incident/Injury Report
Loading...
Editing previous response:
Please fix the highlighted areas below before submitting.
Student Accident/Injury Report
Student Accident/Injury Report
Student Information
First Name
*
Answer Required
Last Name
*
Answer Required
Grade
*
Answer Required
Date of Injury
*
Answer Required
Time of Injury
*
Answer Required
Supervised Activity?
*
Answer Required
Yes
No
Athletic Activity
*
Answer Required
Yes
No
If yes, please list sport
Answer Required
Location Injury Occurred
*
Answer Required
Bathroom
Classroom
New Gym
Old Gym
Cafeteria
Stadium
Pool
Farm
Kitchen
Weight Room
Tennis Courts
Locker Rooms
Other:
Part of Body
*
Answer Required
Ankle
Arm
Elbow
Eye
Face
Finger
Foot
Hand
Knee
Leg
Nose
Tooth
Wrist
Other:
Side of body injured (required for claim form)
*
Answer Required
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
Were parents/guardians notified?
*
Answer Required
Yes
No
Was student taken to a doctor/hospital?
*
Answer Required
Yes
No
If yes, how and by whom?
Answer Required
If taken by school employee or ambulance, name of doctor/hospital
Answer Required
Name of person filling out this form
*
Answer Required
Email address of person filling out this form
*
Answer Required
Confirmation Email
Confirmation Email
*
Email Required
Schools
Staff Directory
Board
Calendar