"School Incident Injury Report Form - Roseville Joint Union High School District"

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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:

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

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:_____________________________________

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:

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

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:_____________________________________

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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