Accident/incident Report Form
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1
2ACCIDENT / INCIDENT REPORT FORM
)
(This form is to be completed for all employee, student and visitor accidents /incidents
INSTRUCTIONS: All school-related accidents/incidents (employee, student, visitor, etc) require Sections I and II of this
Accident/Incident Report to be completed by a supervisor or another employee of the school. The injured person should
not complete this report. The supervisor is required to complete Section III on the reverse side, review the report for
completeness and accuracy, sign and log this report in the accident/incident log book within 24 hours of the
accident/incident. Note: the report (and pictures if any) should then be filed together in a safe and secure location of the
venue. Any copies of this report and any other related materials in conjunction with this report cannot be obtained without
the authorization of the supervisor.
SECTION I
PLEASE PRINT OR TYPE ALL INFORMATION
_____________________________________
NAME: ___________________________________________________
(Brief Physical Description)
HOME ADDRESS:
___________________________________________________________________________________________________
Number/Street
City
State
Zip
TELEPHONE NUMBER: (
)_____________________
AGE: ________
DATE OF BIRTH ______________
(required by insurance agency)
_____ EMPLOYEE _____ STUDENT _____ VISITOR (reason for being on premises)___________________________________
SECTION II
ACCIDENT DATA
____
Accident/Injury
____
Theft/Burglary
NATURE OF INCIDENT:
____
Physical Altercation
____
Verbal Confrontation
____
Property Damage
____
Other
DATE OF Accident /Incident: __________
TIME of Accident /Incident: _____________
____AM
____PM
Accident /Incident occurred at: __Inside Venue__ Outside Venue __ Other Location
________________________
(Specify Location)
Specific Location of Accident: __________________________________________________________________________________
(Address / Vicinity / Actual Location)
Briefly explain what happened:
(if an injury, (1) explain activities occurring when injury or illness occurred and what tools, machinery, chemicals, weapons,
were involved, (2) what happened to cause this injury or illness (3) what was the injury or illness (i.e., state the part of body affected and how it was affected) Use
additional paper if needed.
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
What action was taken: Check all actions taken. If more than one, indicate which occurred 1st, 2nd, etc.
First Aid – administered by _____________________________________________
_______
_______
Sent to Hospital/Physician (Name of Hospital/Physician) ____________________________________________________
Pictures Taken (Number of Pictures Taken) _________________________________
_______
_______
Sent Home
Continued Activity (no action taken)
_______
: __________
_________________
_______________
Phone
School Contact/Supervisor:
Name of Witness
)
(if applicable
Person Completing the Report _________________________________________________________
____________
Date:
____________
Reviewed by School Risk Manager _____________________________________________
Date:
Return form same day (or within 24 hours) of accidents/incident for employee, student, or visitor to the
Business Office.
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Parent category: Business