Student Injury Form
Student Name
*
First Name
Last Name
Student ID
*
Grade Level
*
Please Select
PK3
PK4
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
School
*
Please Select
Early Childhood Center
Cottonwood Elementary
Harwood Elementary
Jefferson Elementary
Midway Elementary
Roberts Elementary
South Fork Elementary
Farnsworth Middle
Rigby Middle
Jefferson High
Rigby High
Accident Setting
*
Please Select
Classroom
Gym
Playground
Hallway
Parking Lot
Sports Field
School Transportation
Off Campus
Other
Please Specify Other Location
Date of Accident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Of Accident
*
Hour Minutes
AM
PM
AM/PM Option
Part of body affected. Please be specific, included left or right side of the body.
*
Injury Type ( bruising, abrasion, cut, broken bone, etc.)
*
Describe the physical injuries observed or reported by the injured person
Who assisted the injured person? Specify Name and Title
*
Describe treatment or first aid rendered
*
Disposition of Student
*
Returned to class
Checked out of school
EMS was notified
If EMS was notified, injured person:
transported to the hospital
was assessed by EMS and released
declined transport to hospital
What was student doing when the accident occurred?
*
If there were any witnesses, please provide their names below.
*
Was the parent/guardian contacted?
*
Yes
No
Your Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please verify that you are human
*
Submit
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