School Accident Report Form
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1
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3File: EBBA-E-2
School Accident Report Form
GENERAL INFORMATION
School __________________________________________________________________________________________ o Student
o Employee
A. Name ______________________________________________________________________________________________________________
Last
First
Middle Initial
o
B. Grade _________________________
C. Age __________________
D. Sex
- Male
o
Position ________________________
- Female
********************************************************************************************************************************************
ACCIDENT INFORMATION
A. Time of Accident _____________ a.m. ______________p.m.
Date ______________________
o Yes
o No
B. Supervised Activity?
C.
If yes, person in charge ______________________________________________________________________________________________
D.
Nature of Injury (may be completed after medical examination)
1. o Abrasion
4. o Burn
7. o Fracture
10. o Sprain
2. o Bruise
5. o Concussion
8. o Laceration
11. o Strain
3. o Bump
6. o Dislocation
9. o Puncture
12. o Other
E. Part of Body Injured
I. Head
II. Trunk
III. Arms
IV. Legs
1. o Scalp
1. o Chest
1. o Shoulder
1. o Hip
2. o Back
2. o Abdomen
2. o Upper Arm
2. o Upper Leg
3. o Front
3. o Back
3. o Elbow
3. o Knee
4. o Eyes
4. o Lower Arm
4. o Lower leg
5. o Ear
5. o Hand
5. o Foot
6. o Nose
6. o Fingers
6. o Toes
7. o Mouth
8. o Tooth
9. o Neck
F.
Kind of Accident (check one only)
G. Where Accident HaDl2ened (check one only)
1. o Animal bite or insect bite
1. o Athletic Field
2. o Collision with student (bump, etc.)
2. o Cafeteria
3. o Contact with hot or toxic substance
3. o Classroom
4. o Fall or slip
4. o Gym
5. o Fighting
5. o Hallway
6. o Struck by auto, bike, etc.
6. o Playground
7. o Struck by object (swing, etc.)
7. oRestroom
8. o Student collided with object
8. o School Bus
9. o Other _____________________
9. o Stairway
10. o To or from school
11. o Vocational/Shops/Labs
12. o Other _____________________
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Parent category: Business