Sweetwater City Schools Accident/Injury Report

Sweetwater City Schools Accident/Injury Report
Email of person filing report
example@example.com
Name of Injured Student:
Date of Birth:
Social Security #
Date of this report:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex:
School
Grade
Date of accident:
Time:
AM/PM
Name of Activity or Class?
Details of incident:
What part of the body was injured?
Who witnessed the accident?
What steps have been taken to prevent a recurrence?
Does this child have school insurance?
Parent/Guardian:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
Signature of person filing report
Signature of Principal
*Note: Report should be filled with the Central Office AS EARLY AS POSSIBLE
Should be Empty: