Student Injury Form

Student Injury Form
Student Name*

First NameLast Name
Student ID*
Grade Level*
School*
Accident Setting*
Please Specify Other Location
Date of Accident*

MonthDayYear
Date
Time Of Accident*

Hour Minutes

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 classChecked out of schoolEMS was notified
If EMS was notified, injured person:

transported to the hospitalwas assessed by EMS and releaseddeclined 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?*

YesNo
Your Name*

First NameLast Name
Your Email Address*
example@example.com
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty: