E 3530a Student or Visitor Injury Incident Report

Student/Visitor Injury/Incident Report   E3530a  


  • 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

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




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.*


    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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