Report of Accident/ Injury in the Alma Public Schools
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Building *
Required
Connection to Alma Public Schools *
Date of accident *
MM
/
DD
/
YYYY
Time of accident
Injured's Name *
Address
Telephone
Age
Grade
Sport if applicable
Nature of Injury
Part of the Body Injured
Side of the body?
Clear selection
Specific Location:
Description of Accident *
Degree of Injury:
Number of days absent
Person in charge when accident occurred
Present at scene of accident?
First Aid treatment given at time of injury *
Treatment provided by *
Next step *
Required
Exam Date
MM
/
DD
/
YYYY
Transported by
Parent notified *
Required
Other individual notified
Witnesses
Plan of care
Signature of Submitter *
By typing your name, you are signing this form electronically.
Additional people to email this document to
This form will be transmitted electronically to the required people- Diane Stankewitz  and Tonia Fenn.  Please mark additional people needing this report.  High School, please check Kim Acker for all HS related submissions.  Mark the building administrator for non-sport injury.
Submit
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