EBBB-E 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. One copy will be sent to the Superintendent's Office the day the accident occurs if possible; a second copy to be filed in the student's file in the school office; and a third copy will be given to the school nurse.
TIME AND PLACE OF ACCIDENT
Date: ___________________________________ Time: _____________________________________
School: ________________________________Location: ____________________________________
INJURED PERSON
Name: ______________________________ Age: _____Grade/Teacher: _______________________
Parent's Name: _____________________________________________________________________
Address: __________________________________________________________________________
What was the injured doing when hurt? __________________________________________________
__________________________________________________________________________________
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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: ______________________________________________
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Reported by: ___________________________________
Date of Report: ______________________________ Principal: _______________________________