Student/Visitor Injury Report
Email *
Valley Elementary  *
Brief description of injury location at the school or department *
Playground, admin office, classroom K-1, etc.
Date of Injury *
MM
/
DD
/
YYYY
Time of Injury *
Time
:
Name of Injured Person *
Student ID (if applicable)
How did the injury occur? *
Please provide a detailed description of how the injury occurred.
Employee with Most Knowledge of Incident
Witnesses Present at Time of Injury (if applicable)
Include age (if student) and phone number
Nature of Injury *
Part of body and type of injury
What type of first aid was applied and by whom? *
Disposition of Injured Person *
Return to class, home, doctor, hospital, ambulance
Have the student's parent/guardian been contacted?
Clear selection
What were the parent/guardian's directives? *
Does the injured student have school insurance? 
Clear selection
Comments
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