First Report of Injury

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Complete this form to report an injury. You must also contact your supervisor immediately when reporting an injury.

Which supervisor did you contact? (One of these people listed must be notified.) *

Beth Giese (K-4 Teachers)

Matt Ryan (5-12 Teachers)

Amy Buchal (Special Education Paraprofessionals)

Amy Belcher (Community Ed, Knights Kids, Preschool)

Paul Clauson (Maintenance/IT)

Employee Name (First and Last Name) *

Date of Claimed Injury *

YYYY

Time of Injury *

Time

Time employee began work on date of injury *

Time

What was the injury (cut, scratch, bruise, etc.) or illness (include the part(s) of the body)? *

How did the injury or illness occur, what was the employee doing before the incident? *

What tools, equipment, machines, objects, or substances were involved? *

Did the injury occur on employer's premises? *

Yes

Required

Location injury occurred on/off premises. (i.e. classroom number/name, commons, gym)? *

Did you seek medical treatment? *

None

Minor on-site treatment by school nurse or another staff

Visit to a Clinic or ER

If you visited a Clinic or ER, please list name of physician and facility. Send supporting paperwork to the district office.

Were there any witnesses to the incident? If so, Please list first and last name(s) of witness.

Submit

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