School Accident Report Form – Fill Out and Use This PDF

The School Accident Report Form is a structured document used by The School Board of Polk County to record the specifics of accidents involving students. This form details the student's personal information, accident timing, location, and a comprehensive description of the accident, including any involved equipment and the immediate actions taken post-incident. To ensure that all necessary details are captured accurately for a prompt response and record-keeping purposes, filling out this form is crucial.

Ensure the safety and well-being of students by meticulously completing the School Accident Report Form. Click the button below to start the process.

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School Accident Report Form PDF Details

When accidents happen at school, it's crucial to have a clear, comprehensive record of the event, which is where the School Accident Report Form comes into play. Designed by The School Board of Polk County, this form serves as a meticulous record-keeping tool that captures all essential details of an unfortunate incident involving a student. From basic information such as the student's name, home address, school details, sex, age, and grade to the specific time and place where the accident occurred, every element is crucial. Moreover, it dives deeper by seeking a detailed description of the accident, including what the student was doing at the time, the location on campus, and any equipment, tool, or machinery involved. It also inquires about the teacher in charge, any direct blood contact, the first aid treatment provided, and further actions taken like sending the student to the nurse, home, a physician, or even the hospital. Furthermore, it mandates documenting communication with the parents and listing any witnesses. The form highlights that in instances of direct blood contact, it is essential to inform involved parties that specific confidential information, particularly concerning HIV and Hepatitis, cannot be disclosed by Polk County Schools. Final sections of the form are reserved for remarks and signatures from the principal and teacher, validating the accuracy of the recorded information. This comprehensive document is not just a bureaucratic necessity; it's a crucial part of ensuring the safety and well-being of students, providing a factual basis for understanding how accidents in schools occur, and laying the groundwork for preventive measures.

Question	Answer
Form Name	School Accident Report Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	50
Avg. time to fill out	8 min
Other names	student accident report form template, accident report for accident that happen at school, school accident report, accident form for school

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THE SCHOOL BOARD OF POLK COUNTY

STUDENT ACCIDENT REPORT FORM

Name ____________________________ Home Address _________________________________________________


School ____________________________________________________ Sex:		M F Age: _____ Grade ________
Time Accident Occurred: Hour ________ A.M. ________ P.M.	Date __________________________________
Place of Accident: School Building _____ School Grounds _____		To or From School ________

DESCRIPTION OF THE ACCIDENT

List student activity at time of accident, location on campus of accident , list any equipment, tool, or machinery that was

involved. Describe in detail the events leading up to the accident, and the accident itself:

____________________________________________________________________________________________________

________

____________________________________________________________________________________________________

________

____________________________________________________________________________________________________

________

____________________________________________________________________________________________________

________

ADDITIONAL INFORMATION

Teacher in charge when the accident occurred ______________________________________________________________

Present at the scene of accident ____ Yes ____No

Direct Blood Contact ____Yes ____ No Persons involved __________________________________________________

First Aid Treatment _____ By (Name)

___________________________________________________________________

Sent to School Nurse ____ By (Name) ___________________________________________________________________

	Sent Home	_____ By (Name)
	____________________________________________________________________
Sent to Physician	_____ By (Name) ___________________________________________________________________

Physician’s Name: ___________________________________________________________________________________

Sent to the Hospital ____ By (Name) ___________________________________________________________________

Was a parent or other individual notified? ____ Yes ____ No When? __________ How?

_________________________

Name of individual notified: ___________________________________________________________________________

By whom? (Enter Name) ______________________________________________________________________________

Witnesses: 1. ______________________________________ 2. ____________________________________________

3.______________________________________ 4. ____________________________________________

REMARKS

In all occurrences of direct blood contact, persons involved or responsible persons should be informed that confidential

information concerning HIV and Hepatitis is not available from or through Polk County Schools.

Principal ___________________________ Date ________ Teacher __________________________ Date _________

How to Edit School Accident Report Form Online for Free

Filling out the student incident report template ensures that all necessary actions and precautions are taken promptly at school.

1. Student Identification

Please write the student's full name involved in the accident. Also, provide the home address, city, and zip code to ensure clear identification.

2. School Details

Record the name of the school where the student is enrolled. Specify the student’s sex by marking "M" for male or "F" for female. Fill in the student's age and grade at the time of the accident.

student injury report template empty fields to consider

3. Accident Timing

Note the exact time the accident occurred, specifying AM or PM. Include the full date of the accident to maintain an accurate timeline.

4. Location of Accident

Indicate the precise location of the accident by checking the appropriate box: inside the school building, on school grounds, or to/from school.

5. Description of the Accident

Describe the student's activity at the time of the accident, the specific location on campus, and any equipment, tools, or machinery involved. Elaborate on the sequence of events leading up to and including the accident.

Finishing student injury report template stage 2

6. Additional Information

Specify the teacher in charge at the time and mark whether they were present at the scene. Note any direct blood contact and list all persons involved.

7. Medical Response

Record any first aid treatment provided and by whom. If the student was sent to the school nurse, sent home, or referred to a physician or hospital, include the names of those who facilitated each action.

Filling out student injury report template part 3

8. Notification Details

Indicate whether a parent or other individual was notified about the accident. Provide details on how and when the notification was made and who made it.

9. Witnesses

You are required to list the names of individuals who witnessed the accident. Space is provided on the school accident report template to list up to four persons. For each witness, clearly write their full name.

10. Final Remarks and Signature

Include any additional remarks that may be helpful in understanding the incident further. The principal and the teacher should sign and date this incident report template for schools.

School Accident Report Form – Fill Out and Use This PDF

School Accident Report Form PDF Details

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