Accident Report Form
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4This form is to be completed by the appropriate employee(s) as soon as possible after an accident occurs.
Madison County
Madison Southern High School
District Name:
School Name:
Brandon Watkins
625-6148
Principal’s Name:
School Phone: (859)
Date Reported:
Date of Accident:
Time:
AM
PM
Supervising Employee:
Claimant’s Name:
Last Name
First Name
Middle Initial
Claimant’s Address:
(859)
City
State
Zip Code
Home/Cell Phone #
Claimant’s Age:
Date of Birth:
Sex:
Grade:
Parent’s Name (if student):
Work Phone Number (
)
Nature of Injury
Place of Accident
Body Part Injured
Scratch
Concussion
Classroom
Gymnasium
Ankle
Foot
Leg
Fracture
Head Injury
Hallway
Parking Lot
Arm
Face
Nose
Bruise
Sprain
Bathroom
Sidewalk
Back
Finger
Teeth
Burn
Cut/Puncture
Cafeteria
Stairs
Neck
Hand
Wrist
Dislocation
Bite
Playground
Athletic Field
Eye
Knee
Shoulder
Other:
Other:
Other:
Describe accident and injury in detail (Attach additional sheet(s) if needed):
Were efforts made to contact the parent/guardian about the accident?
Yes
No
Was first aid administered?
Yes
No
By whom?
Was the student:
Sent home
Sent to physician
Sent to hospital
Is the student covered by Student Accident Insurance?
Yes
No If yes, please list the company name, address, and phone
number.
IF MEDICAL OR HOSPITAL TREATMENT WAS REQUIRED, PLEASE COMPLETE THE FOLLOWING:
(Attach a copy of medical bills, if available)
Name and address of doctor or hospital:
Witness (Name, address & phone number):
Signature of Person Completing the Report
Date
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