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Santa Ynez Valley Union High School District
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Public Incident/Injury Report
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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
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