Student-Visitor Injury Report
Complete for all student and visitor injuries on school property.
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School Name *
Injured Party's Name *
Incident Date *
MM
/
DD
/
YYYY
Injured Party's Phone Number *
Injured Party's Date of Birth *
MM
/
DD
/
YYYY
Injured Party's Sex *
Injured Party's Address *
Injured Party's Grade Level (if applicable)
Description of the Accident (How did the accident happen? What was the injured person doing? What tool, machine, or equipment was involved?) *
What Teacher/Supervisor/Administrator was responsible for the area? *
Witnesses - Name and Phone Number (if applicable)
Location *
Required
Type of Injury *
Required
Body Part(s) Affected *
Required
Was First Aid applied? *
Nurse notified? *
Parent/Guardian called? *
Injured person released to: *
Report Completed by *
Title: *
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