Date and Time of Accident

Location

• Classroom

• Playground

• Hallway

• Sports Field

Name of Child

Age

Grade/Class

Parent/Guardian Name

Contact Number

Type of Incident

• Fall

• Collision

• Injury During Activity

Description of Incident

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 Administered?

• Yes

• No

Medical Attention Needed?

• Yes

• No

Immediate Actions Taken

Name of Reporting Person

Parent/Guardian Notified?

• Yes

• No

Time of Notification

Name of Reporting Staff Member

Position/Role