Western Mennonite School Accident Report
Name of Injured:
Student _____
Employee Reporting:
Job Title:
Witnesses:
Guest _____
Name:
Phone Number:
Name:
Phone Number:
Staff _____
Contact guardian Obtain and attach a written statement from witness(es) Turn this form in to the Business Office
Date of Accident:
/
/
Physical Location of Accident:
Describe activity or incident:
Response by School Employees:
Medical Treatment:
Response by Student / Parent or Guest:
Approximate Time of Accident:
am
pm