Incident/Injury Form
Person Completing this form:
First Name
Last Name
Date and Time of Incident
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Person Injured or Involved
First Name
Last Name
Guardian Name
First Name
Last Name
Give a detailed account of the injury or incident:
List any witnesses (specific names)
How was it handled? (Did they need first aid care? Was parent called? Was medical assistance needed?)
Where are we now?
The issue was resolved.
The issue requires followup.
Any other information it would be helpful for us to know?
Submit
Should be Empty: