NON-EMPLOYEE INCIDENT REPORTING FORM (Use for Students and Visitors)
Notify your Principal’s Office immediately (within 24 hours) for all incidents resulting in personal injury.
Personal Information
Name of Injured Party
First Name
Last Name
Local Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Student's Grade
Student's Age
Visitor's Purpose
Back
Next
Incident Information
Date of Incident
-
Month
-
Day
Year
Date
School Name
Please Select
Ben Franklin
Career Impact Academy
Century
Community
Discovery
Grand Forks Central
Head Start
Kelly
Lake Agassiz
Lewis & Clark
MSEC
Phoenix
Red River
Schroeder
South
Twining
Valley
Viking
Wilder
Winship
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Date Reported
-
Month
-
Day
Year
Date
Description of Incident. Please print. (How did it happen? What was the injured person doing? What, if any, tool, machine orequipment was involved? Who was responsible for the area? Any witnesses? Use back side if necessary.
Witness Name, City, State:
Witness Name, City, State:
Witness Name, City, State:
Witness Name, City, State:
Back
Next
Injury Information
Location
Please Select
Athletic Field
Bus
Bus Stop
Cafeteria
Classroom
Gymnasium
Hallway
Laboratory
Locker Room
Maintenance Area
Office
Playground
Restroom
Sidewalk
Swimming Pool Area
Stairs-Inside
Stairs-Outside
Theater or Stage
Vocational Shops
Other
Other (describe)
Type of Injury
Please Select
Abrasion
Amputation
Asphyxiation
Bite (animal or insect)
Bite (human)
Burn (chemical)
Burn (heat)
Dislocation
Electrical Shock
Head injury
Laceration
Fracture
Poisoning
Puncture
Repetitive Motion
Sprain/Strain
Other
Other (describe)
Body Part(s) Affected
Please Select
Abdomen
Ankle
Arm
Back
Chest
Ear
Eye
Face
Finger
Foot
Hand
Head
Leg
Mouth
Tooth
Wrist
Other
Other (describe)
Back
Next
Immediate Action Taken
None
First Aid provided
Medical Ambulance called
School Nurse notified
Parent/Guardian Notified
Principal Notified
Given by
By:
First Name
Last Name
Time of Call
Hour Minutes
AM
PM
AM/PM Option
Name of Parent/Guardian Notified
First Name
Last Name
Parent/Guardian Telephone Number
Please enter a valid phone number.
Injured person released to:
Self
Home
Class
Physician
Hospital
Other
Time Released
Hour Minutes
AM
PM
AM/PM Option
Back
Next
Report Completion
Report Completed By
First Name
Last Name
Title
Reporting Person's Telephone Number
Please enter a valid phone number.
Reporting Person's Signature:
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: