Collierville High School (Collierville, TN) Athletics

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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: _____________________