School Accident Report Form Page 2
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3File: EBBA-E-2
ACCIDENT DESCRIPTION
Describe the accident in your own words. Please give all details so that this accident report may be used to prevent other similar accidents.
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POST-ACCIDENT INFORMATION
o Yes
o No
A. Was first aid given?
By Whom ______________________________________________________________
Description of first aid _______________________________________________________________________________________________
o Yes
o No
B. Was parent or other responsible person notified?
By whom _________________________________________________________________________________________________________
If no, explain _______________________________________________________________________________________________________
o Yes
o No
C. Advised on tetanus immunization?
o Injured, sent home. If so, was he/she accompanied?
o Yes
o No
D.
o Injured, sent to physician. Name of physician __________________________________________________________________________
o Injured, sent to emergency room. Name of hospital _____________________________________________________________________
E. Days absent from school or work __________
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ACTION TAKEN
A. Instructional
1. o Discussed at staff meeting
4. o Personal instruction given to injured
2. o Discussed in each class as part of regular instruction
5. o Personal instruction given to person in charge
3. o Discussed with parent
6. o Presented as a subject of assembly program
B. Policy or Corrective Action
1. o Discussed with school principal as a follow -up
2. o Principal notified
SIGNATURES
Witness
Title
Person giving first aid
Witness
Title
2
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