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Accident Report Form
This form requires Javascript to be enabled for submission and authorization.
*
Required
Injured Person
Name:
*
required
Sex:
Date of Birth:
Must contain a date in MM/DD/YYYY format
Address:
Phone:
Phone:
Student
Parent
Staff
Visitor
Name of Parent/Guardian (if minor):
Address:
Details
Date of Accident:
*
required
Must contain a date in MM/DD/YYYY format
Description of the incident in detail (include what the injured person was doing at the time):
*
required
What was the injury?
*
required
Where did the injury occur? (Please be as specific as possible)
*
required
Emergency procedures followed at time of incident:
*
required
Where was the injured person taken
Nurses Office
Hospital ER
Doctor's Office
By whom?
Person the school notified:
When:
By whom?
Parent's response:
Comments:
Witnesses (you may wish to attach signed statements)
Was the injured person participating in an activity at the time of incident:
Any equipment involved in the injury?
Information about Reporter
Your Name:
*
required
Role
*
required
Date and Time:
*
required
Email:
*
required
More notes:
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