JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Silverdale Accident Report
Please fill out the form below as completely as possible to ensure we have accurate information on-hand for each Accident/Incident. Note optional fields if time is limited.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
This form is being submitted by:
*
Please provide your full name.
Your answer
Date of event
*
MM
/
DD
/
YYYY
Time of event
*
Time
:
AM
PM
Exact location
*
Your answer
Type of Accident
*
Slip/Trip
Fall
Overexertion
Body Reaction
Allergic Reaction
Other:
Required
Description of what happened and detailed explanation of body part(s) injured (ie, For example: Left ear, pinky and ring fingers on left hand, left knee).
*
Your answer
Personal Information
Who was involved?
*
Preschool Student
Elementary School Student
Middle School Student
High School Student
IMPACT Student
Adult
Required
Did this take place during Early Birds & Night Owls?
*
Choose
Yes
No
Was this an athletics-related accident?
*
Choose
Yes
No
Was this a fine arts-related accident?
*
Choose
Yes
No
First Name
*
Your answer
Last Name
*
Your answer
Grade
If applicable
Choose
Preschool
Kindergarten
1
2
3
4
5
6
7
8
9
10
11
12
Gender
*
Male
Female
If after-hours and a member of the Crisis Management Team is not available, was the Parent/Guardian contacted?
Yes, we had a conversation
Yes, we left a voicemail
No contact was attempted
Other:
Clear selection
Employee who contacted Parent/Guardian
Your answer
Next
Page 1 of 3
Clear form
Never submit passwords through Google Forms.
This form was created inside of Silverdale Baptist Academy.
Report Abuse
Forms
