Student Injury Report

Student Injury Report
Submitted by: Date of Report:  
1st person of authority notified:    Parent/Guardian notified by: 
Affected Student's Information
Last Name:First NameMI: 
Date of Birth:   
Room number:Teacher: 
Known medical conditions:  
Date of Event:Time of Event: 
Was protective gear provided? Was protective gear worn?  
Location of event (be as specific as possible, e.g., room 249, gym):  
List all people who witnessed the incident:  
Injury Information
Type of Injury (use Ctrl+ to select multiple types):    Other: 
1.  What side of the body?  1.  Body part/s injured?   
2.  What side of the body?  2.  Body part/s injured?   
3.  What side of the body?  3.  Body part/s injured?   
Nature of Injury:

How did the event occur? (Include cause, antecedants. DESCRIBE IN DETAIL

Nurses Report
Nurse's Name:  Date: 
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