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.
Cause of Injury/Incident (Check all that apply)
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Physical Injury (Check all that apply)
*
Affected Body Part(s) BE SPECIFIC (Also need left or right, part of head, part of back, which digit, as applicable) |
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Describe the activity of the student at the time of the incident * |
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Describe how the incident occurred * |
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Describe any unsafe acts or conditions |
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Student's description of what happened * |
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Who was notified?
Name and relationship to student |
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What happened to the student after the incident? * (Check
ALL that apply)
Witness description of what happened |
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Description of Immediate Aid Given |
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Student subjective statement re physical condition |
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Additional Followup by School RN (incude date and signature) |
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