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)
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?
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?
Method of reporting (Call, VP, Text, Email or In-Person)
Date Reported to Supervisor
Time Reported to Supervisor
Parent Contacted?
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)
Reviewed by Health Service Director
Date

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

Student Accident/Injury Report