Student Accident Form
This form is designed to inform the school nurse and admin team of a student that has suffered an injury. Regarding Concussions, it is also to initiate the Return to Learn protocol for the classroom and school day. This would be in addition to the Return to Play protocol for athletics.
Date of Injury *
MM
/
DD
/
YYYY
Time of Injury *
Time
:
Student Name *
Your answer
Location of Injury (Stadium, Gym, Etc) *
Your answer
In what Sport did this Injury Occur? *
Your answer
What was Injured and Narrative of How Injury Occurred. *
Your answer
Describe First Aid Given *
Your answer
Who gave the First Aid? *
Your answer
Suspected Concussion? *
Were Parents Notified? *
Was Student Directed to Visit Hospital or Doctor? *
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