DCRSD Report of Injury Form

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This form must be completed in it's entirety within 24 hours of a DCRSD injury.

Email *

School Nurse/School *

Principal/School *

Date of Injury *

YYYY

Time of Injury *

Time

Check One of the Following to Identify the Injured Party *

Student

Employee/Staff (If an employee is seeking medical attention, an MIAA form must be completed as-soon-as-possible )

Visitor (non-employee, non-registered student)

Other:

Full Name of Injured Party *

Student ID# (If Applicable)

Was the parent or guardian notified of said injury

Yes

Clear selection

Home Address of Injured Party *

Contact Number of Injured Party *

Date-of-Birth (DOB) of Injured Party *

YYYY

Describe, in great detail, how the injury occurred and what the injured individual was doing when the injury occurred *

Describe, in great detail, the nature of the injury with qualifying terms like left, right, body part, observations, etc. *

Describe, in great detail, the nature of first-aid given or medical treatment recommended/sought *

School Principal and School Nurse must be notified of said injury as soon as possible. *

Understood (by checking this box you take full responsibility and liability if this did not occur)

Full name of the individual completing this form *

Submit

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