School Incident Injury Report Form
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1
2Roseville Joint Union High School District
NOTICE OF PRIVILEGED AND CONFIDENTIAL MEDICAL INFORMATION
SCHOOL INCIDENT INJURY REPORT
Release of this document will be provided
to the appropriate requesting party by the Site Principal
This report is to be completed for all student and visitor injuries, including, but not limited to: head, neck, eyes, teeth, ears, joints, broken bones,
lacerations, stitches, amputations, etc.
Important: Complete form in pen
Grade:
9
10
11
12
Other:
NAME OF INJURED PERSON: __________________________________________________________
Male
Female
NAME OF PARENT: ________________________________ ADDRESS:___________________________________________
PHONE #: _________________________ DATE OF INCIDENT: _________________ HOUR: __________
a.m.
p.m.
WHERE DID ACCIDENT OCCUR?__________________________________________________________________________
Nature of Accident
Part of Body Injured
Abrasion
Head Injury
Abdomen
Eye*
Head
Bruise/Bump
Fracture
Ankle*
Face
Knee*
Burn
Laceration
Arm*
Finger*
Leg*
Cut
Puncture
Back
Foot*
Teeth
Convulsion
Shock
Chest
Hand*
Wrist*
Dislocation
Sprain
Elbow*
* indicate:
left
right
both
Other ____________________________________
Other ___________________________________
_________________________________________
________________________________________
WAS THE INJURED PARTY TREATED BY THE SCHOOL NURSE?
YES
NO
WAS THE PARENT NOTIFIED?
YES
NO TIME: ___________ BY WHOM?________________________________
DESCRIBE FIRST AID ADMINISTERED AT SCHOOL AND BY WHOM___________________________________________
_________________________________________________________________________________________________________
HOW DID INCIDENT OCCUR? If you did not observe the incident directly, what was reported to you and by whom (Be Specific)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
INJURED PARTY DISPOSITION:
Released to Parent/Guardian
Recommended to have MD evaluation
911 transported
_________________________________________________________________________________________________________
WITNESS(ES) TO INCIDENT:
NAME:_______________________________PHONE:_____________ADDRESS:_____________________________________
NAME:_______________________________PHONE:_____________ADDRESS:_____________________________________
THIS NOTICE COMPLETED BY: ___________________________________ POSITION:_____________________________
Principal’s Signature
Date: ____________________
: ___________________________________________________
Form #153, rev. 8-28-00, 7-12-12lj, 7-16-12lj
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