School Student Injury and Accident Report Form

Documents a student injury or accident, first aid rendered, witnesses, and parent or guardian notification for liability and health records.

Submission Notice

• Date of Report
• Time of Report
• Reporter Name
• Reporter Role
• Incident Location
• Date of Incident

Student Information

• Student Name
• Student ID
  Optional if your school uses another unique identifier for record matching.
• Grade Level
• Was the student under school supervision at the time?

Incident Details

• Incident Type
• Description of What Happened
  Provide a brief factual account of the event, including what the student was doing and how the injury occurred.
• Body Part Affected
• Injury Severity
• Were emergency services called?
• Emergency Services Details

First Aid and Medical Response

• Was first aid provided?
• First Aid Provided
• Was the student referred for medical evaluation?
• Medical Referral Details

Witnesses and Notifications

• Were there witnesses?
• Witness Names
  List witness names and brief statements only if needed for follow-up.
• Was a parent or guardian notified?
• Notification Method
• Time of Notification

Follow-Up and Review

• Immediate Follow-Up Actions
• Additional Notes
• Does this incident require administrative review?