Student Accident Report Form

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STANDARD STUDENT ACCIDENT REPORT FORM
Part A. Report ALL accidents to Students Occurring Anywhere, Day or Night
1.
Name:
Home Address:
2.
School:
Sex: M:
F:
Age:
Grade or classification:
3.
Time accident occurred: Hour
A.M.;
P.M.
Date:
4
Place of Accident:
School Building
School Grounds
To or from School
Home
Elsewhere
5.
Abrasion
Fracture
Description of the Accident
Amputation
Laceration
How did accident happen? What was student doing? Where was
Asphyxiation
Poisoning
student? List specifically unsafe acts and unsafe conditions existing.
Bite
Puncture
Specify any tool, machine or equipment involved.
Bruise
Scalds
Burn
Scratches
Concussion
Shock (el.)
Cut
Sprain
Dislocation
Other (Specify)
Abdomen
Foot
Ankle
Hand
Arm
Head
Back
Knee
Chest
Leg
Ear
Mouth
Elbow
Nose
Eye
Scalp
Face
Tooth
Finger
Wrist
Other (specify)
6.
Degree of Injury:
Death
Permanent
Impairment
Temporary Disability
Non-disabling
7.
Total number of days lost from school:
(To be filled in when student returns to school)
Part B. Additional Information on School Jurisdiction Accidents
8.
Teacher in charge when accident occurred (Enter name):
Present at scene of accident:
No:
Yes:
9.
First-aid treatment
By (Name):
Sent to school nurse
By (Name):
Sent home
By (Name):
Sent to physician
By (Name):
Physician's Name:
Sent to hospital
By (Name):
Name of hospital:
10.
Was a parent or other individual notified? No:
Yes:
When:
How:
Name of individual notified:
By whom? (Enter name):
11.
Witnesses: 1. Name:
Address:
2. Name:
Address:
12.
Specify Activity
Specify Activity
Remarks
Athletic Field
Locker
What recommendations do you have for pre-
Auditorium
Pool
venting other accidents of this type?
Cafeteria
School Grounds
Classroom
Shop
Corridor
Showers
Dressing Room
Stairs
Gymnasium
Toilets and
Home Econ.
washrooms
Laboratories
Other (specify)
Signed: Principal:
Teacher:
(National Safety Council-Form School 1)
STANDARD STUDENT ACCIDENT REPORT FORM
Part A. Report ALL accidents to Students Occurring Anywhere, Day or Night
1.
Name:
Home Address:
2.
School:
Sex: M:
F:
Age:
Grade or classification:
3.
Time accident occurred: Hour
A.M.;
P.M.
Date:
4
Place of Accident:
School Building
School Grounds
To or from School
Home
Elsewhere
5.
Abrasion
Fracture
Description of the Accident
Amputation
Laceration
How did accident happen? What was student doing? Where was
Asphyxiation
Poisoning
student? List specifically unsafe acts and unsafe conditions existing.
Bite
Puncture
Specify any tool, machine or equipment involved.
Bruise
Scalds
Burn
Scratches
Concussion
Shock (el.)
Cut
Sprain
Dislocation
Other (Specify)
Abdomen
Foot
Ankle
Hand
Arm
Head
Back
Knee
Chest
Leg
Ear
Mouth
Elbow
Nose
Eye
Scalp
Face
Tooth
Finger
Wrist
Other (specify)
6.
Degree of Injury:
Death
Permanent
Impairment
Temporary Disability
Non-disabling
7.
Total number of days lost from school:
(To be filled in when student returns to school)
Part B. Additional Information on School Jurisdiction Accidents
8.
Teacher in charge when accident occurred (Enter name):
Present at scene of accident:
No:
Yes:
9.
First-aid treatment
By (Name):
Sent to school nurse
By (Name):
Sent home
By (Name):
Sent to physician
By (Name):
Physician's Name:
Sent to hospital
By (Name):
Name of hospital:
10.
Was a parent or other individual notified? No:
Yes:
When:
How:
Name of individual notified:
By whom? (Enter name):
11.
Witnesses: 1. Name:
Address:
2. Name:
Address:
12.
Specify Activity
Specify Activity
Remarks
Athletic Field
Locker
What recommendations do you have for pre-
Auditorium
Pool
venting other accidents of this type?
Cafeteria
School Grounds
Classroom
Shop
Corridor
Showers
Dressing Room
Stairs
Gymnasium
Toilets and
Home Econ.
washrooms
Laboratories
Other (specify)
Signed: Principal:
Teacher:
(National Safety Council-Form School 1)

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