A student who has been injured on school property must fill out an accident form as soon as possible following the injury.
 

School Name:

Your Name:

Your Home Address:

Your Home Phone Number:

Social Security Number:

Date of Accident:  Time of Accident:
In your own words, describe what happened:
 
 
 
 

What physical problems are you experiencing as a result of this injury?

Did you report this injury to a school employee?  If not, why not?

Date Reported:                                                            Employees Name:
What were you doing at the time of the accident?
Did you go to the hospital/clinic?

Address of hospital/clinic:

Name of treating physician:

Additional comments:

Date:                       Signature: