When a school-aged child is injured, it is important to make sure the correct paperwork is filed with the school administration. The School Accident Report Form can help make this process easier. This form can be used to report any type of injury that occurs while at school. It includes information on how the injury happened, what treatment was given, and contact information for parents or guardians. Having this form handy can help ensure that all necessary information is collected in case of an accident.
You will find info about the type of form you need to submit in the table. It can show you how much time it will require to complete school accident report form, what parts you will have to fill in, and so on.
| Question | Answer |
|---|---|
| Form Name | School Accident Report Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | accident form template for schools, school accident report, accident report for accident that happen at school, example of a report about accident at school ground |
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 _________