Need and Injury report form?

Please feel free to use this simple injury report form to keep track of where injuries are occuring.

Student Injury Report

Student Injury Report Form

Instructions

This form is to be completed immediately following the occurrence of any injury that is severe enough to:

Cause the loss of one-half day or more of school
Warrant medical attention and treatment (i.e. school nurse, M.D., E.R., etc.), and/or
Require reporting according to School District policy.
Number Description of Each Number
1-6 Self explanatory.
7 Do not file a form until you have filled in days missed. If student is going to be absent for an extended period of time, use parent’s estimate. If no school is missed, check less than ½.
8-11 Self explanatory. Record the amount of time child was in the nurse’s office. Please include H or M. H= hours: M=minutes (ie. 1h:40m).
12 Collision with person includes injuries which result from interactions between players from incidental or intended contact. Hit with object includes that the student got hit by an object (ball, backpacks, etc). Fall injuries are those when the student falls from equipment or falls while running. Collision with obstacle includes contact when the child collides into an object (playground equipment, fence, etc.). Injury to self occurs when a child got injured because of an action he/she carried out.

Height of fall – Report the height from where the child fell.

13 Self explanatory.
14 Describe surface over which injury occurred.
15 In the small box indicate the number of the activity that the child was doing when he/she got injured.
16 Self explanatory. See attached document with pictures of each piece of equipment.
17 Briefly describe specifically how the incident happened. Make sure to include all names of witnesses present. If additional space is needed, continue on another sheet of paper and attach.

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