JMU 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
*
-
Month
-
Day
Year
Date
Time
*
Hour Minutes
AM
PM
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:
*
Report Submitted By
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: