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Incident and Injury Report Form

This form should be completed any time there is an incident that should be documented in writing, and any time a student is injured and medical attention is needed. If the incident includes a behavior report/incident of a student, you must also report this in Ed Handbook.

Person completing this form(Required)
MM slash DD slash YYYY
Time(Required)
:
Location of Incident(Required)
MM slash DD slash YYYY
When was the Principal notified of the incident?(Required)
:
Was anyone injured during/as a result of this incident?(Required)
Who was injured?(Required)

Student Name(Required)
Name of person injured(Required)
Reported by:(Required)
Nature of injury/injuries(Required)

What immediate action was taken?(Required)

Where was the person sent after the injury?(Required)

Family member/emergency contact contacted(Required)
MM slash DD slash YYYY
Time family/emergency contact was attempted(Required)
:
Result of family/emergency contact attempt(Required)

Drop files here or
Max. file size: 512 MB.

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