Community Services Incident/Injury Report

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Student Last Name *

Student First Name *

Grade *

Parent or Guardian *

School participant attends *

S.G. Knight

Lincoln

Lindbergh

Middle School

MOL

MOLMS

High School

Other:

Date of injury *

YYYY

Time of injury *

Time

Please write a short description of the incident. *

Name(s) of staff member(s) present? *

What activity was the participant attending? *

Referred to... *

Doctor

On site trainer

Parent/Guardian

Other:

Required

First aid observations or treatments *

Date the incident/injury is being reported: *

YYYY

Additional comments

Please type your first and last name as a digital signature below

By writing your name below you are verifying the above information as an accurate account of the events of the injury and treatments post injury.

Digital Signature *

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