Student Injury Report Form
Referring Teacher
*
D. Astin
N. Barnhill
D. Barrutia
J. Bennett
S. Bennett
B. Blanco
S. Burke
S. Canty
S. Carpenter
M. Choate
B.T. Cook
C. Clegg
L. Parker
D. Craner
J. Dickson
T. Ditlefsen
M. Fraley
B. Fraley
K. Fuller
T. Hafer
C. Hall
R. Hall
B. Hansen
H. Harm
J. Hicks
M. Ho Chee
K. Kaiser
S. LeBlanc
A. Loosli
B. Loosli
G. Maki
W. McGhee
G. Moon
S. Moses
C. Mauldin
D. Norris
I. Requa
D. Ridenour
N. Rinderknecht
R. Robbins
K. Rogers
T. Rowlands
A. Sandell
S. Seering
T. Siler
H. Sorensen
J. Spooner
M. Stewart
S. Young
A. Brossy
J. Mulch
B. Cook
J. Jacobson
S. Skousen
J. Williams
Student Name
First Name
Last Name
Grade
Date of Injury
-
Month
-
Day
Year
Date
Time of Injury
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Parents Contacted
Yes
No
First Aid Given
Ice
Washed Wound
Kept Mobile
Observed
Stopped Bleeding
Applied Dressing
Other
Body Part Injured
Ear
Eye
Face
Head
Neck
Scalp
Abdomen
Back
Chest
Groin
Shoulder
Hip
Buttocks
Side
Knee
Ankle
Foot
Lower Leg
Upper Leg
Toes
Hand
Finger
Thumb
Wrist
Lower Arm
Upper Arm
Elbow
Other
Type of Injury Suspected
Laceration/Abrasion
Sprain/Stretch
Fracture
Bruise/Contusion
Burn
Dislocation
Scratch/Surface Cut
Other
Action Taken
Parent took Home
Returned to class
Called 911
Parent took to doctor
Parent took to ER
Other
Explanation of Accident/Injury
Accident Location
Classroom
Playground
Gym
Bus
Hallway
Bathroom
Dance Stage
Other
Surface
Blacktop
Carpet
Concrete
Dirt
Grass
Ice/Snow
Wood Chips/ Bark
Other
Activity
Fighting
Climbing
Running
Walking
Sports
Playground Equiptment
Rough Housing
Jumping
Ball
Other
Signature
Submit
Should be Empty: