Injury Report Home > About Us > Child Safety > Injury Report Vision & Mission History Philosophy of Education Expected Student Outcomes School Board School Profile Child Safety Injury Report Facilities Where is Mountainview? Contact Us MOUNTAINVIEW ACCIDENT/INJURY REPORT FORM 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 Bite Bump/Blow Burn/Scald Cut/Scrape Dislocation Fracture Imbedded Object Poisoning Puncture Sprain Other 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) Abdomen Back Chest Rib Cage Face Finger Head Mouth Nose Scalp Tooth 11. Which part of the body? (2) Ankle (Right) Ankle (Left) Arm (Right) Arm (Left) Ear (Right) Ear (Left) Elbow (Right) Elbow (Left) Eye (Right) Eye (Left) Foot (Right) Foot (Left) Hand (Right) Hand (Left) Knee (Right) Knee (Left) Leg (Right) Leg (Left) Wrist (Right) Wrist (Left) 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: * Submit Save For Later