E 3530a Student or Visitor Injury Incident Report

Student/Visitor Injury/Incident Report   E3530a  

INTERNAL USE ONLY

  • Complete this report on-line within 48 hours of injury and mail signed print out to Natalie Bates, District Office.
  • If this injury/incident results in likely medical treatment of the student, complete the Accident Claim Form, give to the parent/visitor and retain a copy.
  • Complete "Student Injury Incident Home Report" for parent.

Fields marked with a red asterisk (*) are required.


School Where
Student Attends *
Student/Visitor *
                                     
Last Name *   First Name *   MI  
Gender *
                                     
Student ID Number *   Birthdate *    
Phone Number * Home Address *    
City *      


Injury/Illness Info

Location Where Injury/Incident Occurred *(i.e. another school, bus, classroom, gym, playground, shop, etc)   
Date of Injury/Incident *  
Time of Injury/Incident *  

Cause of Injury/Incident (Check all that apply) *

                                     
Detail below:
 

Physical Injury (Check all that apply) *

                                
Detail below:
 

Affected Body Part(s) BE SPECIFIC (Also need left or right, part of head, part of back, which digit, as applicable) 
 

Teacher/Supervisor Name  

 Describe the activity of the student at the time of the incident *
 

Describe how the incident occurred *
 

Amount of Supervision
 

Describe any unsafe acts or conditions
 

Describe any safeguards
 

Student's description of what happened *
 

Who was notified?

Name and relationship to student
 
How Notified
 
Time  

What happened to the student after the incident? * (Check ALL that apply)

                                 
Detail below:
 

Witness/First Aid

Was the incident witnessed?
                                     
Witness Name  

Witness description of what happened
 

First Responder  

Description of Immediate Aid Given
 

Nurse / First Aid Provider's Report

Was Nurse Available? *  
                                      		Name     Time Seen    
Who Provided First Aid?   Name?    

Student subjective statement re physical condition
 

Objective
 

Assessment
 

Plan
 

Additional Followup by School RN (incude date and signature)
 

An Accident Claim Form with Part A completed has been provided for the parent specifically for this injury/incident.*
                       

Signatures

Nurse            
    Printed   Signature   Date
             
Form Completed By            
    Printed   Signature   Date
             
Admin Approved By            
    Printed   Signature   Date

Please complete your email address below by adding your username before the @kpbsd.k12.ak.us below. (i.e.: firstInitialLastname@kpbsd.k12.ak.us)

A copy of this form will be emailed to the address you provide after the submit button has been pressed.

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