Incident Report - ISD#879

Please complete this form if you have and Incident to report.
* Reported By:
 
* Your Email Address:
 
Your Phone #:
 
* School:
 
* Student Name:
 
* Grade:
 
Date of Birth:
 
* Date of Incident:
 
* Time of Incident:
 
* Place of Incident:
 
* Description of Incident:
 
Part of Body Injured:
  Ankle
Arm
Back
Elbow
Eye
Face
Finger
Foot
Hand
Head
Knee
Leg
Nose
Scalp
Tooth
Wrist
Other
 
Type of Injury:
  Abrasion
Amputation
Bruise
Burn
Cut
Possible Fracture
Laceration
Puncture
Scratch
Sprain
Other
 
Witness Name(s):
 
* Treatment Given:
 
First Aid Provided by:
 
Type of First Aid Provided:
 
Sent Home by:
 
Sent to Physician by:
 
Name of Physician:
 
Sent to Hospital by:
 
* Parent/Guardian Notification: Was a parent, guardian or other individual notified?
  Yes
No
Name of individual notified:
 
By Whom:
 
How was the above notified?
 
Follow Up:
 
Enter Letters For Verification
* Required Fields