Student Accident Report Form | Russell Branch Institute

Students Full Name: *

Students Address: *

Gender: *

Age: *

Grade: *

Date of Accident: *

Month

Day

Year

Time of Accident: *

Hour

:

Minute

am

pm

Place of Accident: *

Description of Accident

List student activity at time of accident, location on campus of accident, list any equipment, tool, or machinery that was involved. Describe in details the event leading up to the accident, and the accident itself.

Additional Information

Teacher in charge at time of accident: *

Present at scene of accident?: *

Yes

No

Direct Blood Contact?: *

Yes

No

Persons Involved:

First Aid Treatment?: *

Yes

No

First Aid provided by (Name):

Sent to School Nurse?: *

Yes

No

Sent to School nurse by (Name):

Sent to Physician?: *

Yes

No

Sent to Physician by (Name)?:

Physician Name?:

Sent to the Hospital?: *

Yes

No

Sent to the Hospital by (Name)?:

Was the parent or other individual notified?: *

Yes

No

When?:

How?:

Name of the individual notified:

By whom? (Enter Name):

Witness 1:

Witness 2:

Witness 3:

Witness 4:

Name of person filling out this form?: *

Position Held?:

By signing below I acknowledge that all of the above information I have entered is accurate to the best of my knowledge.: *