Injury Report Form

Basic Information

* School

* Form Completed By

* Email

* Incident Type

* Date of Incident

* Time of Incident

* Date Incident Reported

* Name of Injured Party

* Date of Birth

Incident Location

School Address

If Incident Did Not Occur On Campus

Address 1

Address 2

City

State

Zip

* Description of Incident Location

Other Description

Was 9-1-1 Called?

Yes No

Injury Details

Incident Description

* Description of Incident

* Description of First Aid

* Explanation of Incident

Collision with object Collision with person Hit with object Injury for self Playground equipment Slip/Fall Tripped over object Other

Other - Explanation

Medical Treatment

Witnesses & Supervision

Supervising Staff Member

Witnesses (Name, Phone Number, Email)

Photo Documentation

* Picture(s) of injury and/or cause of injury

Please add pictures of both the injury and what caused the injury if possible.

Click to upload or drag and drop

PNG, JPG only (no HEIC) - up to 10MB each

Student Information

Complete this section if the injured party is a student.

Student Grade Level

Parent/Guardian Name

Parent/Guardian Contact Number

Parent/Guardian Contacted?