Name of Injured *

Age *

Sex

Grade

School *

Parent's Name *

Parent's Work Phone *

Home Address *

City *

State *

Zip Code *

Location of Accident *

Date of Accident *

Time of Accident *

Description of Accident (Document with photos of accident area using upload section)

Miscellaneous Information (Condition of Premises, Equipment, Weather, Etc.)

Person In Charge When Accident Occurred *

Immediate Action Taken
First-Aid TreatmentSent to School NurseTaken HomeReferred to DoctorSent to Hospital By

Notification
ParentGuardianDoctorNurseTeacherOther

Disposition
Taken HomeTaken to doctor's officeTaken to hospitalOther

Name

Phone

Address

Name

Phone

Address

Name

Phone

Address

File 1

File 2 (optional)

File 3 (optional)

Person Submitting Report *

Contact Phone No. *

Contact Email *

Signed by Principle/Nurse *

Contact Phone No. *