Student Accident Report Form

Please complete the following form as completely and accurately as possible (essential fields are marked with a *).

General Information

Date Originated:
Monday Oct 23, 2017
* Building:
*Your Name:
*Room #/Area:
*Your email address:
*Student Name:
Student ID:
Student Birth Date:
Student Address:
Student Phone:

Accident Information

*Date of Accident:
*Time of Accident:
*Supervised Activity?
If 'yes', person in charge:

*Nature of Injury

 Possible Fracture
 Animal Bite
 Possible Concussion
 Nose Bleed
 Possible Dislocation
 Insect Bite
 Possible Sprain
 Chipped Tooth
 Possible Strain

*Location of Injury

 Temple (Left)
 Temple (Right)
 Eyes (Left)
 Eyes (Right)
 Ears (Left)
 Ears (Right)
 Shoulder (Left)
 Shoulder (Right)
 Upper Arm (Left)
 Upper Arm (Right)
 Elbow (Left)
 Elbow (Right)
 Lower Arm (Left)
 Lower Arm (Right)
 Hand (Left)
 Hand (Right)
 Wrist (Left)
 Wrist (Right)
 Hip (Left)
 Hip (Right)
 Thigh (Left)
 Thigh (Right)
 Knee (Left)
 Knee (Right)
 Lower Leg (Left)
 Lower Leg (Right)
 Foot (Left)
 Foot (Right)
 Ankle (Left)
 Ankle (Right)

*Where Accident Happened

* Building where incident occurred:
 Athletic Field
 To/From School
 School Bus
 Shower/Dressing Room

Accident Description

*Brief description of accident:

Action Taken

*Was first aid given?
If 'yes', by whom:
Describe injury and treatment:
*Was parent or other designated person notified?
Name of person notified & relationship to student:
Time notified:
Student was sent to:
If sent to 'Other':
Student transported by:
If transported by 'Other':


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321 N. DePeyster St.
Kent OH 44240