THE OFFICIAL SITE OF
Collierville High School Athletics

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Accident/Incident Report

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  1. 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.

  2. A monthly report containing a summary of accidents will be emailed/faxed to Coordinated School Health at the end of the month.

  3. If an accident results in further care from a physician (i.e. broken arm, concussion) immediately email/fax the report to Coordinated School Health.

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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?

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Yes

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No

Student has health plan?

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Yes

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No

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Student requires routine or emergency medication?

Yes

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No

Parent Present

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Student released to parent

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Student Returned to Class/activity

Student kept in clinic for observation

Other

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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

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No

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Type of Injury:

Accident/Incident Report

Break

Bump

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Broken/Chipped Tooth

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Burn

Bruise

Nosebleed

Dislocation

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Cut

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Puncture

Scratch/Scrape/Mash

Sprain/Pull/Jam/Twist

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Insect Sting

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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: _____________________

PRIVACY POLICY | © 2019 MASCOT MEDIA, LLC