Accident/Incident Report
This report pertains to an incident/accident or situation that DOES NOT require activating Law Enforcement/Crisis Intervention for an event occurring during regular school hours, school sponsored activities and on buses transporting students and from school and school sponsored activities.
A monthly report containing a summary of accidents will be emailed/faxed to Coordinated School Health at the end of the month.
If an accident results in further care from a physician (i.e. broken arm, concussion) immediately email/fax the report to Coordinated School Health.
School Name: _____________________________________________________Date/Time of Incident: _________________________ Student Name: _____________________________________________ Phone Number: _______________________________________ Grade: _______ Age: ______ Race: ______ Sex: ______ Street Address: _________________________________________________ Parent/Guardian notified? ______ Yes ______No ______ Unable to reach parent
Administrator Notified ______ Yes ______ No
Select action taken: (check the appropriate box)
Circle answer for each:
CONTINUED ON BACKSIDE
Student has existing medical condition? | Yes | No |
Student has health plan? | Yes | No |
Student requires routine or emergency medication? | Yes | No |
Parent Present | |
Student released to parent | |
Student Returned to Class/activity | |
Student kept in clinic for observation | |
Other |
Did incident/accident occur while student was supervised? | Yes | No |
Did incident/accident occur during a school-sponsored event? | Yes | No |
Does this student have insurance? | Yes | No |
Type of Injury:
Accident/Incident Report
Break | Bump | Broken/Chipped Tooth | Burn |
Bruise | Nosebleed | Dislocation | Cut |
Puncture | Scratch/Scrape/Mash | Sprain/Pull/Jam/Twist | Insect Sting |
Part Of the Body Injured: ____________________________________________________________________________________________ First Aid treatment applied: ______ Yes ______ No
Other: _________________________________________________________________________________________________________
Describe Activity:
Other: _________________________________________________________________________________________________________________
Location of Incident: _________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Describe how the incident happened: ______________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Describes student’s condition: ______________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Describe action taken by school personnel: _______________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________
Name of Supervising Teacher/Staff Reporting the incident: _____________________________________________________ Signature: _____________________________________________________________________________________________________________ Principal Signature ______________________________________________________________________ Date: _____________________