Accident-Injury Report

This online submittable form is to be used to report any incident, injury or accident. Complete and submit this  form to the Risk Management Department at within 24 hours of the incident, 24 hours a day, 7 days a week.

A. Injured Information:

Time *
Gender *

B. Witnesses (attach signed statements)

C. Describe Accident/Injury (Include part of the body injured)

D.How did Accident/Injury Occur?

Police Report Filed? *

E. First Aid

Was first aid given? *

F. Action Taken

After the incident did the injured: *

G. Parent/Guardian Notification

Were parents/guardians notified? *

H. Equipment 

Was any equipment or object connected with this incident? *

I. Behavior

Did any behavior or activity by injured contribute to the incident/injury? *

J. Other contributing Factors? (Please list)

Please list them

K. Prevention 

How could this incident have been prevented?            

Electronic Signature

Published September 17th, 2019    

* Please Note: Once you submit this form, you'll have the option to print the form contents on the following page.
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