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 kentschools.net email address:
*Student Name:
Grade:
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

 Abrasion/Bruise
 Laceration/Cut
 Possible Fracture
 Animal Bite
 Possible Concussion
 Nose Bleed
 Possible Dislocation
 Insect Bite
 Burn
 Possible Sprain
 Puncture
 Chipped Tooth
 Possible Strain
 Illness
 Other: 

*Location of Injury

Head
 Scalp
 Back
 Front
 Temple (Left)
 Temple (Right)
 Eyes (Left)
 Eyes (Right)
 Ears (Left)
 Ears (Right)
 Nose
 Mouth
 Tooth
 Neck
Trunk
 Chest
 Abdomen
 Back
Arms
 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)
 Finger/Thumb
Legs
 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)
 Toe

*Where Accident Happened

* Building where incident occurred:
 Athletic Field
 Cafeteria
 Classroom
 To/From School
 Auditorium/Stage
 Hallway
 Playground
 Restroom
 School Bus
 Shower/Dressing Room
 Shop/Labs
 Stairway
 Gym
 Outdoors
 Other: 

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
330-676-7600