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CHRHS Accident/Injury Report
Use N/A if not applicable.
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* Indicates required question
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
N/A
Required
Transported to:
*
Home
Physician
Hospital
N/A
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
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