Student Accident Report
These reports are to be filled out and handed to the school nurse "ANY TIME" a student is injured at school or at a school related or sponsored activity.
This is important to the teacher or supervisor involved and also to the school.
PLEASE DO NOT FAIL TO FILL OUT EVEN IN CASE OF MINOR INJURIES.
Name of Student *
Your answer
Grade *
Your answer
Date Report Filed *
MM
/
DD
/
YYYY
School: *
Your answer
Date of Accident: *
MM
/
DD
/
YYYY
Time of Accident: *
Time
:
Accident Jurisdiction (check one) *
Injury and Description of Accident *
Your answer
If Supervisor was NOT a witness, to whom was the injury reported and when:
Your answer
Signature of Teacher/Staff Person and/or Supervisor *
Your answer
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