Student Injury Incident Report

Student Injury Incident Report

Student Incident Report
For insurance purposes

School building
Student First Name
Student Last Name
Student Grade
Incident Date:
Incident Time: (include am or pm)
Description of Location of Incident:
Your name (incident reporter):
Reporting Date:
Reporting Time: (include am/pm)
Please describe how the alleged incident occurred.
Who was supervising the student when the incident occurred?
Witness 1 Name, Address, Telephone #:
Witness 2 Name, Address, {Phone #):
Witness 3 Name, Address, Phone #:
Was first aid rendered?
Did student remain at school for the remainder of the day/activity?
Your Name:
Your Email:

To validate your submission, please answer the following math problem:

8 + 5 =
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