CHRHS Accident/Injury Report
Use N/A if not applicable.
Your name and title *
Your answer
Injured Person:
Name *
Your answer
Age *
Your answer
Grade *
School *
Parent/Guardian Name(s) *
Your answer
Address
Your answer
Phone
Your answer
Time and Place of Accident/Injury
Date *
MM
/
DD
/
YYYY
Time *
HH:MM (24 hr format)
Your answer
Location *
Please be specific as to the building and location.
Your answer
Program/Sport *
Please be specific as to sport, class, program, etc.
Your answer
Other students involved
Please list names.
Your answer
Accident/Injury Details
Nature of injury
Type of Accident/Injury *
Check any that apply. If OTHER, please specify.
Required
Affected Side
Part of the body *
Check any that apply.
Required
Cause of Accident/Injury
Description of how the accident/injury occurred. *
Your answer
Did teacher/staff member/coach witness incident? *
Name(s) of witness(es):
Your answer
First Aid *
Describe action taken.
Your answer
Transported by: *
Required
Transported to: *
Required
Notes
Your answer
Notifications
Parent/Guardian at event? *
Required
Date Parent/Guardian was notified:
MM
/
DD
/
YYYY
Time Parent/Guardian was notified:
HH:MM (24 hr format)
Your answer
Who notified the parent/guardian or "other"?
Your answer
Describe any medical treatment administered later by physician or other, if known.
Your answer
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