"School Incident Injury Report Form - Roseville Joint Union High School District"
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2Roseville Joint Union High School District
NOTICE OF PRIVILEGED AND CONFIDENTIAL MEDICAL INFORMATION
SCHOOL INCIDENT INJURY REPORT
Release of this document will be provided
to the appropriate requesting party by the Site Principal
This report is to be completed for all student and visitor injuries, including, but not limited to: head, neck, eyes, teeth, ears, joints, broken bones,
lacerations, stitches, amputations, etc.
Important: Complete form in pen
Grade:
9
10
11
12
Other:
NAME OF INJURED PERSON: __________________________________________________________
Male
Female
NAME OF PARENT: ________________________________ ADDRESS:___________________________________________
PHONE #: _________________________ DATE OF INCIDENT: _________________ HOUR: __________
a.m.
p.m.
WHERE DID ACCIDENT OCCUR?__________________________________________________________________________
Nature of Accident
Part of Body Injured
Abrasion
Head Injury
Abdomen
Eye*
Head
Bruise/Bump
Fracture
Ankle*
Face
Knee*
Burn
Laceration
Arm*
Finger*
Leg*
Cut
Puncture
Back
Foot*
Teeth
Convulsion
Shock
Chest
Hand*
Wrist*
Dislocation
Sprain
Elbow*
* indicate:
left
right
both
Other ____________________________________
Other ___________________________________
_________________________________________
________________________________________
WAS THE INJURED PARTY TREATED BY THE SCHOOL NURSE?
YES
NO
WAS THE PARENT NOTIFIED?
YES
NO TIME: ___________ BY WHOM?________________________________
DESCRIBE FIRST AID ADMINISTERED AT SCHOOL AND BY WHOM___________________________________________
_________________________________________________________________________________________________________
HOW DID INCIDENT OCCUR? If you did not observe the incident directly, what was reported to you and by whom (Be Specific)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
INJURED PARTY DISPOSITION:
Released to Parent/Guardian
Recommended to have MD evaluation
911 transported
_________________________________________________________________________________________________________
WITNESS(ES) TO INCIDENT:
NAME:_______________________________PHONE:_____________ADDRESS:_____________________________________
NAME:_______________________________PHONE:_____________ADDRESS:_____________________________________
THIS NOTICE COMPLETED BY: ___________________________________ POSITION:_____________________________
Principal’s Signature
Date: ____________________
: ___________________________________________________
Form #153, rev. 8-28-00, 7-12-12lj, 7-16-12lj
Roseville Joint Union High School District
NOTICE OF PRIVILEGED AND CONFIDENTIAL MEDICAL INFORMATION
SCHOOL INCIDENT INJURY REPORT
Release of this document will be provided
to the appropriate requesting party by the Site Principal
This report is to be completed for all student and visitor injuries, including, but not limited to: head, neck, eyes, teeth, ears, joints, broken bones,
lacerations, stitches, amputations, etc.
Important: Complete form in pen
Grade:
9
10
11
12
Other:
NAME OF INJURED PERSON: __________________________________________________________
Male
Female
NAME OF PARENT: ________________________________ ADDRESS:___________________________________________
PHONE #: _________________________ DATE OF INCIDENT: _________________ HOUR: __________
a.m.
p.m.
WHERE DID ACCIDENT OCCUR?__________________________________________________________________________
Nature of Accident
Part of Body Injured
Abrasion
Head Injury
Abdomen
Eye*
Head
Bruise/Bump
Fracture
Ankle*
Face
Knee*
Burn
Laceration
Arm*
Finger*
Leg*
Cut
Puncture
Back
Foot*
Teeth
Convulsion
Shock
Chest
Hand*
Wrist*
Dislocation
Sprain
Elbow*
* indicate:
left
right
both
Other ____________________________________
Other ___________________________________
_________________________________________
________________________________________
WAS THE INJURED PARTY TREATED BY THE SCHOOL NURSE?
YES
NO
WAS THE PARENT NOTIFIED?
YES
NO TIME: ___________ BY WHOM?________________________________
DESCRIBE FIRST AID ADMINISTERED AT SCHOOL AND BY WHOM___________________________________________
_________________________________________________________________________________________________________
HOW DID INCIDENT OCCUR? If you did not observe the incident directly, what was reported to you and by whom (Be Specific)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
INJURED PARTY DISPOSITION:
Released to Parent/Guardian
Recommended to have MD evaluation
911 transported
_________________________________________________________________________________________________________
WITNESS(ES) TO INCIDENT:
NAME:_______________________________PHONE:_____________ADDRESS:_____________________________________
NAME:_______________________________PHONE:_____________ADDRESS:_____________________________________
THIS NOTICE COMPLETED BY: ___________________________________ POSITION:_____________________________
Principal’s Signature
Date: ____________________
: ___________________________________________________
Form #153, rev. 8-28-00, 7-12-12lj, 7-16-12lj
WHAT TO DO WHEN AN
INJURY OCCURS
Gather FACTS of
Deliver Incident
Injury occurs to student,
incident and complete
Report ASAP to
parent or member of
Incident Report in
Principal’s Office
general public.
pen, legibly and
for further
completely.
distribution to:
School Nurse and
District Office
Business Dept.
Note: Incident Reports
contain confidential
information. Students
are prohibited from
viewing/handling
Incident Reports.
Incident Reports may
become legal documents
in defense of litigation.
Statements written
should be facts and not
opinions.
Incident Reports are
subject to California
Public Records Act
(CPRA) release.
If a party requests a
copy of an Incident
Report, notify the Site
Principal for his/her
release of document.
H:\Lisa\FORMS\School Incident Report - Form 153 rev 7-16-12lj.doc7/5/12
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