St. Bartholomew School Health Office Incident Report

St. Bartholomew School Health Office

Incident Report Fom
Student Name

First NameLast Name
Grade
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Is this a Head Injury?

NoYes
Nature of Injury/Incident (Abrasion, Burn, Head Injury, etc.)
Part of Body Involved (Arm, Face, Knee, etc.)
Location of Incident/Injury (Gym, Hall, Stairs, etc.)
Activity (P.E. Class, Recess, etc.)
Description of Incident
Student Description of the events surrounding the incident:
Staff description of the incident (if different):
First Aid Treatment
Head Injury Information

Your child was given first aid for a head injury. The Health Service procedure for this type of injury is to apply a cold compress to the injury and have the child lie flat for 30-40 minutes. If none of the signs listed below appear, the child can return to class.

Please contact your doctor if you note any of the symptoms listed below:
- Persistent headache. Do not give any medication until you check with your doctor.
- Drowsiness of increased irritability. Inability to easily arouse from sleep.
- Nausea or vomiting
- Changes in respiration - difficulty breathing or bluish tinge to skin.
- Blurred or double vision, or unequal pupils.
- Inability to move all extremities, or unsteady gait.
- Fluid or bleeding from ears.
- Difficulty speaking - slurred or incoherent speech.
- Twitching or convulsions.
- Loss of consciousness.
Action Taken
Time Parent/Guardian Notified

Hour Minutes

AM/PM Option
Returned to classSent homeSent to Physician/Urgent CareSent to Hospital
Person Completing Report
Parent Email 1
Parent Email 2
Should be Empty: