HPU Accident Report Form

HPU Accident Report Form

INSTRUCTIONS: TO BE COMPLETED IMMEDIATELY when an incident involving a student occurs requiring attention BEYOND BASIC FIRST AID. The school employee who witnessed the injury and any other witnesses need to also complete the accident report form.
Name*

First Name Last Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date*

MonthDay Year
Date
Time*

Hour Minutes

AM/PM Option
Description of Incident:*
Describe Injury (e.g. bite, fracture, bump, cut, sprain, etc.):*
Part of body injured (be specific):*
Disposition of student (e.g. back to campus, home, hospital, etc.):*
Was blood or other bodily fluid involved?*
What type of first aid was provided?*
Witness(es) Present at Time of Accident (Name, Address, Phone Number):*
Any other details regarding the incident:*
Report submitted by:*

Clear
Report Submitted By*

First Name Last Name
Date*

MonthDay Year
Date
Should be Empty: