Accident Report Form

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Accident Report Form

If in doubt, call 911 immediately!

Always advise the injured person to seek qualified medical advice!

Name of injured person: ______________________________________

Date of Injury: _____/_____/_____ Time of injury: ___________ AM/PM

Brief description of Injury: __________________________________________________________________________________________________________________________________________________________________________________________

Details of how injury happened: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(for additional space use the back of this page or attach additional pages)

__________________ __________________ ________________

Staff member                        Staff member                        Staff member

List all students in the class or witnesses: __________________________________________________________________________________________________________________________________________________________________________________________

How was injury treated by reporting staff member? __________________________________________________________________________________________________________________________________________________________________________________________

If injured person was less than 18 years of age, was the guardian notified? ______________

To whom was the injured person released? _______________________________________

Did you recommend medical treatment? _________________________________________

How did the injured person get medical treatment? _________________________________

On a separate piece of paper have all the witnesses describe what they saw and attach those papers to this form.

Notify the manager of the school of the accident.  After completing this form, keep a copy for the school’s records and forward the original to the manager at the corporate office.

Signature of employee completing this form