Policy #4.19.2-Accident Report Form

ACCIDENT REPORT FORM                                                                      4.19.2


 

Accidents to pupils on school premises should be reported on this form and submitted to the principal. The report should be made on the day of the accident. If the accident is serious, a telephone report should be made in addition to the written report.

 

 

Name of Pupil Involved:

 

 

Grade:                                     Homeroom:                 Age:

 

Name of Parent (or Guardian):

 

Address:

 

Date of accident:                     Hour:                           Place:

 

Accident occurred in which class:

 

Description of accident:

 

 

 

 

Action taken:

 

 

 

 

Was the accident witnessed by the teacher in charge of the class?

 

 

Was group  teacher-supervised at the time of accident?

 

 

Teacher's signature:

 

 

Is the pupil insured?               Type of insurance:

 

Has the accident insurance form been completed and forwarded to agency?

 

Principal:

 


 

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