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. OneThe copyoriginal will be sentkept towith the Superintendent'sstudent Officehealth the day the accident occurs if possible; a second copy to be
filed in the student's filerecords in the school office;nurse’s andoffice. aThis thirddocument copyis will
be given to the school nurse.confidential.
TIME AND PLACE OF ACCIDENT
Date: ___________________________________________________________________ Time: _________________________________________________________________________
School: ________________________________Location: ___________________________________________________________________
INJURED PERSON
Name: __________________________________________________________ Age: _____Grade/Teacher: _______________________
Parent's Name:
_____________________________________________________________________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: _____________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Parent/Emergency Contact Notified:
____________________________________________________________________________________________________
Contacted by: __________________________________________ at ____________________(time)
How was the contact made: ________________________________(phone, email, voicemail, etc.)
ADDITIONAL FOLLOW-UP INFORMATION: ______________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Reported by: ___________________________________
Date_____________________________Date of Report: ___________________________________________________________
Principal: _______________________________
Revised: 5/2022