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Student-Visitor Injury Report
Complete for all student and visitor injuries on school property.
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* Indicates required question
School Name
*
Ferdinand Elementary
Pine Ridge Elementary
Cedar Crest Intermediate
Forest Park Jr./Sr. High School
Injured Party's Name
*
Your answer
Incident Date
*
MM
/
DD
/
YYYY
Injured Party's Phone Number
*
Your answer
Injured Party's Date of Birth
*
MM
/
DD
/
YYYY
Injured Party's Sex
*
Male
Female
Other:
Injured Party's Address
*
Your answer
Injured Party's Grade Level (if applicable)
Your answer
Description of the Accident (How did the accident happen? What was the injured person doing? What tool, machine, or equipment was involved?)
*
Your answer
What Teacher/Supervisor/Administrator was responsible for the area?
*
Your answer
Witnesses - Name and Phone Number (if applicable)
Your answer
Location
*
Athletic Field
Bus
Bus Stop
Cafeteria
Classroom
Gym
Hallway
Science Lab
Locker Room
Maintenance Area
Office
Playground
Restroom
Sidewalk
Stairs Inside
Stairs Outside
Vocational Shop
Stage Area
Other:
Required
Type of Injury
*
Abrasion
Amputation
Asphyxiation
Bite (Animal/Insect)
Bite (Human)
Burn (Chemical)
Burn (Heat)
Concussion
Dislocation
Electrical Shock
Laceration
Fracture
Poisoning
Puncture
Sprain/Strain
Other:
Required
Body Part(s) Affected
*
Abdomen
Ankle
Back
Chest
Ear
Eye
Face
Finger
Foot
Hand
Head
Leg
Mouth
Tooth
Wrist
Other:
Required
Was First Aid applied?
*
Yes
No
Other:
Nurse notified?
*
Yes
No
Other:
Parent/Guardian called?
*
Yes
No
Other:
Injured person released to:
*
Self
Parent/Guardian
Ambulance/Hospital
Other:
Report Completed by
*
Your answer
Title:
*
Your answer
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