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Accident Report
Student Name
(Required)
First
Last
Age
(Required)
Home Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Guam
Hawaii
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Massachusetts
Michigan
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Mississippi
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New York
North Carolina
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Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Accident
(Required)
Time of Accident
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Name of Person Making This Report
(Required)
First
Last
Part Injured
(Required)
Abdomen
Ankle
Arm
Back
Chest
Head
Leg
Scalp
Hand
Hip
Face
Shoulder
Knee
Eye
Elbow
Ear
Foot
Nose
Finger
Toes
Mouth
Teeth
Wrist
Other
Location of Injury
(Required)
Athletic Field
Auditorium
Cafeteria
Classroom
Corridor/Hall
Dressing Room
Gymnasium
School Bus
Street/Driveway
Locker
Shower
Bus Loading Area
School Grounds
Stairs
Restroom
Playground
Lab
Sidewalk
Parking
Other
Degree of Injury
(Required)
Nondisabling
Permanent Impairment
Temporarily Disability
Period
(Required)
Afterschool
Assembly
Before School
Class Change
Class Time
Lunch Period
PE Class
Recess
Other
Name of teacher(s) or person(s) in charge when accident occurred
(Required)
First
Last
What was student doing when injured? How did injury occur? List unsafe acts and conditions existing. Specify:
(Required)
First Aid Treatment By:
(Required)
Sent to Nurse:
(Required)
Yes
No
Additional Notes:
Sent to Physician:
(Required)
Yes
No
Additional Notes:
Sent to Hospital:
(Required)
Yes
No
Additional Notes:
Witness contact information:
Witness contact information:
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