STUDENT ACCIDENT REPORT  
(Circle First Applicable Answer in Each Group)

 
1. Name: ____________________________________     Sex:       1.   Male    2.     Female     Grade ______    Age ______
 
2. School Name: ________________________________ Date Occurred: ____/____/____ Date Reported: ____/____/____  
 
3. Time:  _____________ A.M./P.M.  01 Before School Hours 02 During School Hours
       03 After School Hours 04 School not in Session
 
4. Place of Accident:

01 Phys. Ed. Class  07 Auditorium  13 Playground 
02 Organized Athletics 08 Library 14 School Grounds
03 Gymnasium 09 Restroom 15 Cafeteria
04 Locker Room 10 Classroom/office 16 Bus
05 Science Lab 11 Halls
17 Automobile
06 Manual/I.A. 12 Stairways  

** Other (explain) __________________________________________________________
 
5. Source of Injury:

01 Children Fighting  08 Bee Sting/Animal Bite 15 Vandalism 
02 Horseplay 09 Door/Window 16 Structural Failure
03 Sharp Object 10 Hot Surface 17 Falls/Slips
04 Falling/Flying Object 11 Electricity 18 Unintentional Act
05 Gymnastics/Equipment 12 Chemicals/Paint 19 Cond. of premises 
06 Phys Ed Equipment 13 Snow/Ice/Freezing Rain 20 Punishment 
07 Machinery/Equipment 14 Fire/Smoke/Flames

    ** Other (explain) __________________________________________________________
 
6. Body Part Injured:

01 Abdomen  08 Face
15 Knee 22 Scalp 
02 Ankle 09 Finger 16 Leg 23 Shoulder 
03 Arm 10 Foot
17 Lung 24 Toe
04 Back 11 Groin 18 Mouth 25 Wrist 
05 Chest 12 Hand 19 Multiple
 
06 Ear
13 Heart
20 Neck  
07 Eye 14 Hip
21 Pelvis 

    ++ No Noticeable Injury        
    ** Other (explain) ___________________________________________________________
 
7. Nature of Injury:

01 Abrasion 09 Contusion 17 Infected/Irritated
02 Amputated 10 Crushed 18 Lacerated
03 Asphyxiated 11 Dislocated
19 Overexerted 
04 Bite 12 Fracture/Broken 20 Poisoned 
05 Burn 13 Frozen
21 Punctured
06 Bumped 14 Hernia 22 Sprained/Strained
07 Burn 15 Inflamed/Swollen 23 Shock/Trauma 
08 Concussion 16 Cut/Scratch 24 No Noticeable Inj.

** Other (explain) ___________________________________________________________
 
8. Narrative Description of Accident: ________________________________________________________________________
 ______________________________________________________________________________________________________
 ______________________________________________________________________________________________________
 
9. Names of Witnesses: ________________________________________________________________________________
 
10. Action Taken: 

01 Back to Class 04 Nurse Called 07 First Aid 
02 Parent Contacted 05 Physician Contacted 08 Home Visit 
03 Sent Home 06 Hospital   

 ** Other (explain) __________________________________________________________
 
Signature ______________________________________________________________________  Date _________________
 
Nurse Assessment: ___________________________________________________________________________________________
____________________________________________________________________________________________________________
__________________________________________________________Nurse’s Signature__________________________________ 

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