Student Name * First Name Last Name Student Date of Birth * MM DD YYYY Student Grade * K 1 2 3 4 5 6 7 8 9 10 11 12 Select * Male Female Date of Incident * MM DD YYYY Time of Incident * Hour Minute Second AM PM Parent/Guardian Name * First Name Last Name Parent/Guardian Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian Cell Phone * (###) ### #### Parent/Guardian Work Phone (###) ### #### Parent/Guardian Home Phone (###) ### #### Location of Incident * Athletic Field Bus Cafeteria Classroom Gymnasium Hallway Parking Lot Playground Restroom Stairway Courtyard Other: Please Explain Time of Incident Recess Before School Lunch After School P.E. Class Special Area Class Change Field Trip Unknown Athletic Practice/Session Athletic Team/Competition Equipment Involved Surface * Check All That Apply Asphalt Carpet Concrete Dirt Gravel Gymnasium Floor Ice/Snow Lawn/Grass Mat(s) Sand Synthetic Surface Tile Wood Chips/Mulch Other: Please Specify Type of Injury * Check All That Apply Abrasion/Scrape Bite Bump/Swelling Bruise Burn/Scald Cut/Laceration Dislocation Fracture Pain/Tenderness Puncture Sprain Other Location of Injury * Check All That Apply Head Eye Ears Nose Mouth/Lips Tongue/Teeth Jaw Chin Neck/Throat Collarbone Shoulder Upper Arm Elbow Forearm Wrist Hand Finger Fingernail Chest/Ribs Back Abdomen Groin Genetals Pelvis/Hip Leg Knee Ankle Foot Toe Response * Returned to Class Sent/Taken Home Days of School Missed Length of Time Restricted Diagnosis Explanation Diagnosis of Care Provided to Student Additional Comments Thank you!
