Student Accident/Injury Form

This form is to be completed by a school administrator, teacher, or fellow staff that was present
during the time of the incident. Be sure to provide as much information as possible and as
accurately as possible.

Breie

School Name: ________________________________________ Birth Date:

____________________
Legal Last Name: _____________________________ Legal First Name: ______________________
Gender: __________ Date of Accident: ______________ Time of Accident: ____________________
Brief Description (one sentence):
Description of Accident: What? How? When? Equipment?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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Circle of Highlight Appropriately

Accident/Injury
Type
Abdominal/Interna
l
Abrasion
Accidental Injury
Anaphylaxis
Back Injury
Behavioral
Incident
Break
Bruise
Burn
Chemical Accident
Concussion
Dental Injury
Dizziness
Drugs
Electrical Accident
Eye Injury
Fall
Fracture

Cause of Injury
Accidental Injury

Abrasion

Location
Description
Bus

Broken Glass
Burn
Bus Accident
Car Accident
Collision with
Object/Surface
Collision with
Other Student
Debris
Defective
Playground Equi.
Fall from Equip.
Fighting
Gym/PE Class

Blister
Break
Bruise
Concussion
Contusion

Cafeteria
Classroom
Gym
Hallway
Library

Ankle
Arm
Back
Buttocks
Chest

Cut

Off School
Grounds
Other:
PE Class

Elbow

Playground
Playground Equip
Restroom

Finger
Foot
Hand

School Grounds
Shop
Stairs

Head
Knee
Leg
Mouth
Multiple

Heat Related
Hitting
Intentional
Other:
Playground
Accident
Pushing

Nature of Injury

Dislocation
Dizziness
Irritation
Laceration
Loss of
Consciousness
Minor Injury
Required EMS
Off-Site Care
Scratch
Shock
Sprain

Anatomical
Location
Abdominal

Eye
Face

Neck

Head Injury
Heat-Related
Emergency
Human/Animal
Bite
Laceration/Cut
Loss of
Consciousness

Running
Self-Injury

Medical Injury
Neck Injury
Other:
Overexertion
Pain/Swelling
Psychiatric
Emergency
Puncture
Respiratory
Emergency
Scratch
Seizure
Slip
Sprain/Strain
Sting
Stitches
Trip

Wet Floor

Swelling
Tooth Injury

Sports Related
Thrown Objects
Tripping

Nose
Other:
Shoulder

Interscholastic
Activity: (list
below)

Teeth
Thorax

Toe
Wrist

PE:
Baseball
Basketball
Football
Hockey
Other:
PE Class General
Soccer
Swimming
Track
Volleyball

Contact Information (Parent or Guardian):

Contact Name: ___________________________________________ Parent Notified: Yes___ No___
Contacted By: ________________________________ Additional Information: __________________
Wittness Information:
Witness Name: ____________________________________ Witness Phone: ___________________
Witness Address: ___________________________________________________________________
Treatment Information:
Where was the student taken: _________________________ Treated By: ______________________
Treatment Given: No___ Yes___ Ice Applied___ Other___
Police/911 Information:
Police Called: Yes__ No___ Follow Up Date:____________________
Procedure Description:_______________________________________________________________
Follow Up Action Information:
Risk Management Notified: Yes__ No__ First Aid Provided: Yes__ No__
Student sent home: Yes__ No__
Report Completed By Print &Signature/Date:
_____________________________________________
Principal Reviewed Sign and Date: _____________________________________________________
Follow Up Narrative: ________________________________________________________________