Date and Time of Accident

Location

• Classroom

• Playground

• Hallway

Name of Injured Party

Grade/Class

Parent/Guardian Contact Number

Type of Incident

• Fall

• Collision

• Equipment Issue

Describe the Accident

Witness Name 1

Phone number

Witness Name 2

Phone number

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Were there any injuries?

• Yes

• No

If yes, please input the details of the injury sustained.

Body Part(s) Affected

First Aid Given?

• Yes

• No

Medical Attention Needed?

• Yes

• No

Immediate Actions Taken

Name of Reporting Person

Teacher/Supervisor Name

Phone Number