EBBB-E School Accident Report Form
FILE: EBBB-E (1)
SCHOOL ACCIDENT REPORT FORM
Whenever an injury occurs in school, on school grounds, or during any school sponsored activity, this Accident Report Form should be filled out. Once the form has been completed, please bring it to the main office for processing. The original will be kept with the student health records in the school nurse’s office. This document is confidential.
TIME AND PLACE OF ACCIDENT
Date: ________________________________ Time: ____________________________________
School: ________________________________Location: _______________________________
INJURED PERSON
Name: ____________________________ Age: _____Grade/Teacher: _______________________
Parent/Guardian’sName:______________________________________________________
Address: __________________________________________________________________________
What was the injured doing when hurt? __________________________________________________
WITNESSES TO THE ACCIDENT AND ANY ADDITIONAL PERSONNEL BROUGHT TO SCENE:
DESCRIPTION OF INJURY & CARE GIVEN: _____________________________________________
Name Parent/Emergency Contact Notified:________________________________________________
Contacted by: __________________________________________ at ____________________(time)
How was the contact made: ________________________________(phone, email, voicemail, etc.)
ADDITIONAL FOLLOW-UP INFORMATION: ______________________________________________
Reported by: _____________________________Date of Report: _____________________________
Principal: _______________________________
Revised: 5/2022