REPORT OF INJURY TO STUDENT

REPORT OF INJURY TO STUDENT
All student injuries must be reported to the Health Services Department within 24 hours -

Regardless of Severity.

Security, Health Services, or other authorized personnel may be assigned to investigate injuries if necessary.

Please complete all questions and provide a detailed description of the injury.
Reporting Staff Member Name (You)*

First NameLast Name
Student Name*

First NameMiddle NameLast Name
Student Date of Birth*

MonthDayYear
Date
FemaleMaleOther
Date and Time of Injury*

MonthDayYear
Date
Hour MinutesAM/PM Option
Location of Injury (Building)*
Location of Building or Grounds Where Injury Occurred (Select All That Apply)*
In Detail, How Did the Injury Occur?*
What was the Injured Student Doing at the Time of the Accident?*
Name of the Substance or Object that Directly Caused the Injury.*
Describe in Detail the Nature/Extent of the Injury. Be Sure to Indicate in Detail the Body Part Involved:*
Was First Aid Administered? Please Describe the First Aid Provided:*
Did the Injured Student Receive Medical Attention? Describe (Include Name of Hospital/Clinic):*
Eyewitness Comments (if Applicable):*
Comments From the Injured Student:*
Annotate Image Instructions: 1. Select Color – Choose the color you’d like to use for your markings. 2. Select Line Width – Adjust the thickness of the line. 3. Select Pen – Pick the pen tool to begin drawing. 4. Mark Up Diagram – Identify and mark the body parts impacted. Additional Tools Use shapes or add text by clicking the “T” button. If you make a mistake, use the Back button to undo. To start over, click the Clear button at the bottom of the image.
Do You Have Photographs or Video? If So, Please Upload Here.
Name of Principal*

First NameLast Name
Reporting Staff Member Signature*

Clear
Should be Empty: