ACDS Accident Report
Complete this form for all accidents that require child treatment.
Student Name
*
First Name
Last Name
Grade
Preschool Twos
Preschool Threes
PreKindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
Homeroom Teacher
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Date of Accident
*
-
Month
-
Day
Year
Date
Time of Accident
*
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
Was activity supervised?
*
Yes
No
If Yes, faculty who was supervising or witnessed accident:
*
Nature of Injury
*
Scrape
Bruise
Cut/Laceration
Burn
Head Injury (Minor)
Head Injury (Concussion)
Broken Bone or Disclocation
Puncture
Sprain
Strain
Other
Area of Body Injured
*
Head
Eyes
Ear
Nose
Mouth
Teeth
Neck
Chest
Stomach
Back
Shoulder
Arm
Leg
Hand
Finger
Knee
Foot
Toes
Other
Kind of Accident
*
Animal or insect Bite
Collision with other student
Contact with hot or toxic substance
Fall or slip
Fighting
Struck by vehicle (auto, bike, etc.)
Struck by object (swing, ball, bat, etc.)
Student collided with object
Other
Where did accident happen?
*
Classroom
Art
Drama
Gym
Turf Field
Pond
LS Playground
MS Playground
Kitchen
School Bus
Path or Walkway
Hallway or Stairway
Accident Description
*
Describe the accident in your own words. Please give all the details so this accident report may be used to prevent other similar incidents.
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Was First Aid given?
*
Yes
No
Who administered First Aid?
Name
Was parent or responsible person notified?
*
Yes
No
Other
Who Notified parent of responsible person?
Name
Name of responsible person (parent or guardian)?
Parent Name
If no notification was made, please explain why:
Action taken:
*
Student sent home in car of parent or person party
Injured and sent to hospital
Student sent back to classroom
Other
If student was sent home, who picked up student?
Parent or Guardian Name
Report Completed by:
*
First Name
Last Name
Submit
After Incident Follow-up:
Discussed at Administration Meeting
Discussed at Faculty Meeting
Changed Guidelines or Policies
Instructed or Education for Faculty
Instruction or Education for Parents
Instruction or Education for Students
Other
Notes:
Updated by:
Name
Should be Empty: