ACCIDENT REPORT FORM To be filled in at the time of the accident by the person caring for an injured student, faculty or staff member, or visitor to HCHS and filed in appropriate personnel file. Accident Victim’s Name ______________________________________ Age _______ Sex _______ This person is a (circle one)
STUDENT
FACULTY/STAFF MEMBER
VISITOR
Location of Accident _______________________________________________________________ Date ________________ Time ______________ AM or PM Nature of Accident Abrasion Head Injury Bruise/Bump Fracture Burn Laceration Cut Puncture Convulsion Shock Dislocation Sprain Other _____________________________
Part of Body Injured Abdomen Eye* Head Ankle* Face Knee* Arm* Finger* Leg* Back Foot* Teeth Chest Hand* Wrist* Elbow* Other______________________________
__________________________________
________________________________ *Left, Right, Both
Describe what you observed _________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Treatment and disposition ___________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Emergency Contact _______________________________________ ________________________ Name
Was Emergency Contact notified?
Phone
YES
or
NO
Follow-up ________________________________________________________________________ Amount of time lost from school _______________________________________________________
______________________________________ (Signature) Person in Attendance
___________________________________ (Signature) Principal, Teacher or Nurse
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