Injury Report - Mountainview Christian School

MOUNTAINVIEW ACCIDENT/INJURY REPORT FORM

A Staff Member closest to the scene of the accident/place of injury fills out this form within 12 hours of the accident. Please give to your respective principal. Thank you.

1. Name of Student/Staff/Visitor Injured *

2. How old is he/she? *

3. Date & Time of Accident: *

4. Specific Place of Accident: *

5. Date of Report: *

6. Form Submitted by: *

7. Cause of Injury

8. Other(Descripe)

9. Level of Consciousness (Scale 1 to 10 10 = Normal, 1 = Unconscious) (Between 1 and 10)

10. Which part of the body? (1)

11. Which part of the body? (2)

12. Please specify, if needed, more details about nature of injury or part of body injured.

Description of Accident:

How did the accident happen? What action was the person doing? List anything that the person was doing that would have been considered unsafe when the accident occurred. List any tool, machine or equipment that was involved.

13. Answer here:

Action Taken After the Accident:

14. First Aid Given:

YES NO

15. If YES, by whom?

16. Please describe what was done:

17. Transported to Medical Facility for further treatment/examination?

YES NO

18. Name of person & vehicle used to transport the person:

19. Parents Notified:

YES NO

20. If YES, By Whom:

Circle the area that was injured on the person.

Download this picture then upload it to the next step.

(*How to download: right click on the image, then save image as...).

21. Upload The Picture (Circle the area that was injured on the person).

(allowed file types: doc, docx, jpeg, jpg, pdf, png, ppsx, ppt, pptx, txt, zip)

22. Enter Your Email Address: *