Student Injury Report Student injury report form Student Name(Required) First Last Student grade(Required)PreK3PreK4Kindergarten1st2nd3rd4th5th6th7th8thHomeroom Teacher(Required) Description of Incident(Required)Date(Required) MM slash DD slash YYYY Time(Required) Hours : Minutes AM PM AM/PM Location of Incident(Required) Classroom Front playground Back field Back playground Hallway Cafeteria Stairwell Off campus Other Relevant location details (room #; other location, etc.)(Required) Duration of incident(Required) Reported by:(Required) First Last Adult Observer(s)(Required) Person(s) involved in incident(Required) Antecedent(Required) Nature of injury/injuries(Required) Abrasion/scrape Bite Bump/swelling Bruise Burn Cut Dislocation Fracture Puncture Sprain Other Location of injury/injuries (i.e. fractured wrist, cut on forehead)(Required) What immediate action was taken?(Required) Administered first aid Called 911 Other Who administered first aid? What did they do?(Required)Where was the student sent after the injury?(Required) Back to class To the nurse To the hospital Home Other Family member/emergency contact contacted(Required) First Last Date family contact was attempted:(Required) MM slash DD slash YYYY Time family contact was attempted(Required) Hours : Minutes AM PM AM/PM Result of family contact attempt(Required) Called and spoke to family Called – left voicemail Called – no voicemail option Sent text Emailed family Called emergency contact Other Response from person contacted(Required)When was the Principal notified of the injury?(Required) MM slash DD slash YYYY When was the Principal notified of the injury?(Required) Hours : Minutes AM PM AM/PM Person completing this form(Required) First Last Email of person completing this form(Required)
