Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Student Accident Report
Please complete this if a student sustains an injury during school or at a school sanctioned event.
Please forward the follow-up email from the submitted Google Form to your building administrator
.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Date of accident
*
MM
/
DD
/
YYYY
Approximate Time of Incident
Time
:
AM
PM
Student Name
*
Your answer
Where was student? (school name, location, etc.)
*
Your answer
What was the injury?
*
Your answer
Please briefly describe the incident:
*
Your answer
Was this a witnessed event?
*
No
Yes; give name below
Other:
Required
Were parents notified?
*
Yes
No
Were there any actions taken? (911, first aid, sent home, etc.)
*
Your answer
Was the accident the result of an unsafe act or condition? If no, simply respond with a no. If yes, please explain.
*
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Baker School District 5J.
Does this form look suspicious?
Report
Forms
Help and feedback
Help Forms improve
Report
