Accident/Injury Report Form

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Accident/Injury Report Form
Name __________________________
Date ___________________________
What part of the body was injured? ____________________
How did the injury occur? ______________________________
________________________________________________________
________________________________________________________
First Aid treatment provided: ___________________________
________________________________________________________
Parents were notified by:
Phone
In Person
on _____________________ and _______________________.
(date)
(time)
Parent Signature _______________________________________
Provider Signature _____________________________________
Accident/Injury Report Form
Name __________________________
Date ___________________________
What part of the body was injured? ____________________
How did the injury occur? ______________________________
________________________________________________________
________________________________________________________
First Aid treatment provided: ___________________________
________________________________________________________
Parents were notified by:
Phone
In Person
on _____________________ and _______________________.
(date)
(time)
Parent Signature _______________________________________
Provider Signature _____________________________________

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