School Accident Report Form

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File: EBBA-E-2
School Accident Report Form
GENERAL INFORMATION
School __________________________________________________________________________________________ o Student
o Employee
A. Name ______________________________________________________________________________________________________________
Last
First
Middle Initial
o
B. Grade _________________________
C. Age __________________
D. Sex
- Male
o
Position ________________________
- Female
********************************************************************************************************************************************
ACCIDENT INFORMATION
A. Time of Accident _____________ a.m. ______________p.m.
Date ______________________
o Yes
o No
B. Supervised Activity?
C.
If yes, person in charge ______________________________________________________________________________________________
D.
Nature of Injury (may be completed after medical examination)
1. o Abrasion
4. o Burn
7. o Fracture
10. o Sprain
2. o Bruise
5. o Concussion
8. o Laceration
11. o Strain
3. o Bump
6. o Dislocation
9. o Puncture
12. o Other
E. Part of Body Injured
I. Head
II. Trunk
III. Arms
IV. Legs
1. o Scalp
1. o Chest
1. o Shoulder
1. o Hip
2. o Back
2. o Abdomen
2. o Upper Arm
2. o Upper Leg
3. o Front
3. o Back
3. o Elbow
3. o Knee
4. o Eyes
4. o Lower Arm
4. o Lower leg
5. o Ear
5. o Hand
5. o Foot
6. o Nose
6. o Fingers
6. o Toes
7. o Mouth
8. o Tooth
9. o Neck
F.
Kind of Accident (check one only)
G. Where Accident HaDl2ened (check one only)
1. o Animal bite or insect bite
1. o Athletic Field
2. o Collision with student (bump, etc.)
2. o Cafeteria
3. o Contact with hot or toxic substance
3. o Classroom
4. o Fall or slip
4. o Gym
5. o Fighting
5. o Hallway
6. o Struck by auto, bike, etc.
6. o Playground
7. o Struck by object (swing, etc.)
7. oRestroom
8. o Student collided with object
8. o School Bus
9. o Other _____________________
9. o Stairway
10. o To or from school
11. o Vocational/Shops/Labs
12. o Other _____________________
File: EBBA-E-2
School Accident Report Form
GENERAL INFORMATION
School __________________________________________________________________________________________ o Student
o Employee
A. Name ______________________________________________________________________________________________________________
Last
First
Middle Initial
o
B. Grade _________________________
C. Age __________________
D. Sex
- Male
o
Position ________________________
- Female
********************************************************************************************************************************************
ACCIDENT INFORMATION
A. Time of Accident _____________ a.m. ______________p.m.
Date ______________________
o Yes
o No
B. Supervised Activity?
C.
If yes, person in charge ______________________________________________________________________________________________
D.
Nature of Injury (may be completed after medical examination)
1. o Abrasion
4. o Burn
7. o Fracture
10. o Sprain
2. o Bruise
5. o Concussion
8. o Laceration
11. o Strain
3. o Bump
6. o Dislocation
9. o Puncture
12. o Other
E. Part of Body Injured
I. Head
II. Trunk
III. Arms
IV. Legs
1. o Scalp
1. o Chest
1. o Shoulder
1. o Hip
2. o Back
2. o Abdomen
2. o Upper Arm
2. o Upper Leg
3. o Front
3. o Back
3. o Elbow
3. o Knee
4. o Eyes
4. o Lower Arm
4. o Lower leg
5. o Ear
5. o Hand
5. o Foot
6. o Nose
6. o Fingers
6. o Toes
7. o Mouth
8. o Tooth
9. o Neck
F.
Kind of Accident (check one only)
G. Where Accident HaDl2ened (check one only)
1. o Animal bite or insect bite
1. o Athletic Field
2. o Collision with student (bump, etc.)
2. o Cafeteria
3. o Contact with hot or toxic substance
3. o Classroom
4. o Fall or slip
4. o Gym
5. o Fighting
5. o Hallway
6. o Struck by auto, bike, etc.
6. o Playground
7. o Struck by object (swing, etc.)
7. oRestroom
8. o Student collided with object
8. o School Bus
9. o Other _____________________
9. o Stairway
10. o To or from school
11. o Vocational/Shops/Labs
12. o Other _____________________
File: EBBA-E-2
ACCIDENT DESCRIPTION
Describe the accident in your own words. Please give all details so that this accident report may be used to prevent other similar accidents.
********************************************************************************************************************************************
POST-ACCIDENT INFORMATION
o Yes
o No
A. Was first aid given?
By Whom ______________________________________________________________
Description of first aid _______________________________________________________________________________________________
o Yes
o No
B. Was parent or other responsible person notified?
By whom _________________________________________________________________________________________________________
If no, explain _______________________________________________________________________________________________________
o Yes
o No
C. Advised on tetanus immunization?
o Injured, sent home. If so, was he/she accompanied?
o Yes
o No
D.
o Injured, sent to physician. Name of physician __________________________________________________________________________
o Injured, sent to emergency room. Name of hospital _____________________________________________________________________
E. Days absent from school or work __________
***************************************************************************************************************************************************************
ACTION TAKEN
A. Instructional
1. o Discussed at staff meeting
4. o Personal instruction given to injured
2. o Discussed in each class as part of regular instruction
5. o Personal instruction given to person in charge
3. o Discussed with parent
6. o Presented as a subject of assembly program
B. Policy or Corrective Action
1. o Discussed with school principal as a follow -up
2. o Principal notified
SIGNATURES
Witness
Title
Person giving first aid
Witness
Title
2
Adopted: 12/08/97
3

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