JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Reporting Student Injury
Please complete the form when there is a student accident that results in injury. This will be automatically forwarded to the business office for appropriate follow-up.
* Indicates required question
Email
*
Record my email address with my response
Name and position of staff member completing this form.
*
Your answer
Student's Name
*
Your answer
Grade
*
Your answer
Date and Time of injury
*
Your answer
School Employee on supervisory duty:
*
Your answer
Where did the accident occur?
*
Your answer
What happened?
*
Your answer
Describe the injury:
*
Your answer
What first aid was given?
*
Your answer
Outcome of injury? (ex. back to class, went home, called 911, etc.)
*
Your answer
Please list the parent or guardian that was contacted and contact information.
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of WSR Schools.
Report Abuse
Forms
