CHRHS Accident/Injury Report
Use N/A if not applicable.
Sign in to Google
to save your progress.
Learn more
* Required
Your name and title
*
Your answer
Injured Person:
Name
*
Your answer
Age
*
Your answer
Grade
*
9
10
11
12
School
*
CHRHS
Other:
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
Acute
Chronic
Clear selection
Type of Accident/Injury
*
Check any that apply. If OTHER, please specify.
Abrasion
Bite
Bruise
Burn
Cut
Dental
Dislocation
Fracture
Head Injury
Laceration
Object in eye
Puncture
Sprain/Strain
Other:
Required
Affected Side
Left
Right
Part of the body
*
Check any that apply.
Ankle
Arm
Back
Chest
Collar Bone
Elbow
Eye
Face
Finger
Foot
Hand
Head
Hip
Knee
Leg
Lip
Mouth
Neck
Nose
Shoulder
Stomach
Tooth
Wrist
Other:
Required
Cause of Accident/Injury
Description of how the accident/injury occurred.
*
Your answer
Did teacher/staff member/coach witness incident?
*
Yes
No
Name(s) of witness(es):
Your answer
First Aid
*
Describe action taken.
Your answer
Transported by:
*
Parent/Guardian/Other Adult
Ambulance
Student transported him/herself
Required
Transported to:
*
Home
Physician
Hospital
Required
Notes
Your answer
Notifications
Parent/Guardian at event?
*
Yes
No
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
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Five Towns School Districts.
Report Abuse
Forms
