Injury/Accident Report
This form must be completed fully and accurately.
Name of Injured
*
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Grade
Gender
Male
Female
N/A
Event Name
*
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
05
10
15
20
25
30
35
40
45
50
55
Minutes
AM
PM
AM/PM Option
Location/Area/Room
Parent/Guardian Name (if 18 or under)
First Name
Last Name
Parent/Guardian Phone
-
Area Code
Phone Number
Parent/Guardian Email Address
example@example.com
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Injury Info
Please be specific and thorough.
Exact location of accident
Be specific.
Nature of Injury (please only provide facts)
What caused the Injury (please only provide facts)?
Describe activity engaged in at time of accident
Name of supervisor of activity
First Name
Last Name
Witness to injury (name and phone number, if participant)
Witness First Name
Witness Last Name
Witness Phone Number
-
Area Code
Phone Number
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Treatment
Please answer these questions the best you can.
Describe any treatment given at the time of injury
Was injured party taken to a doctor, hospital or medical treatment facility immediately after injury?
Yes
No
If yes, list name of doctor or location
Collect address, phone number, etc. if possible.
Comments (please only provide facts)
Please provide any extra information that may be useful to the situation.
Email
example@example.com
Submit
Should be Empty: