Student Accident Report

Student Accident/Injury Report
This form should be completed and submitted immediately following a student accident.
Student*
Birthdate

MonthDayYear
Reporting Staff Name*
Reporting Staff Email*
example@example.com
Reporting Staff Signature (please sign in box below)*

Clear
Date of Accident*

MonthDayYear
Time of Accident*
Location of Accident*
Nature of Injury*
How did accident happen?*
How could it have been prevented?*
Action Taken:
Reported to Nurse?*

YesNo
Method of reporting (Call, VP, Text, Email or In-Person)
Date Reported to Nurse
Time Reported to Nurse
Name of your Supervisor*
Reported to Supervisor?*

YesNo
Method of reporting (Call, VP, Text, Email or In-Person)
Date Reported to Supervisor
Time Reported to Supervisor
Parent Contacted?*

YesNo
By Whom & Method (Call, VP, Text, Email or In-Person)
Date Parent Contacted
Time Parent Contacted
STOP - Submit the form using the button above. The following is to be completed by the Health Services staff only.
If post-injury care is provided by health services, nursing should complete the following:
What type of care was provided?
Signature of nurse providing care (please sign in box below)

Clear
Reviewed by Health Service Director
Date

MonthDayYear
***Completed copy to be filed in health services.
Should be Empty:

Student Accident/Injury Report