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315

Appendix IV - Accident Report Form 315-4

Procedures

Student Accident Report

 

School Name:________________________________________________________________________

 

Name of Student Involved:  _______________________________________________          Age:  ______

 

Home Room:   ____________________________________    Grade:  _____________

 

Name of Reporting Staff Member:  ________________________________________________________

 

Date of Accident:   _________________________          Date Report Made:  ________________________

                                (Day) (Mo.) (Yr.)                                                                   (Day) (Mo.) (Yr.)

 

Accident Particulars: (time, location, activity, incident description, factors (unusual or otherwise), observances, irregularities): 

 

____________________________________________________________________________________

 

____________________________________________________________________________________

 

Action Taken by Staff Member in Charge:  __________________________________________________

 ____________________________________________________________________________________

 

First Aid or Medical Treatment:  ___________________________________________________________

 

____________________________________________________________________________________

 

Witnesses to Accident:  ________________________________,  ________________________________

 

Principal’s Report:  _____________________________________________________________________

 

____________________________________________________________________________________

 

1. Was an attempt made to contact parents?

a)  Before child taken for medical attention                                       _______________        ________________

                                                                                                           YES                                  NO

b)  After child taken for medical attention                                          _______________        ________________

                                                                                                           YES                                  NO

2.  If parents were contacted, did they refuse or state they

were unable to take the child for medical attention?                           _______________        ________________

                                                                                                         REFUSED                      UNABLE

 

3. If refused or unable, please state reason given:  ____________________________________________

 

___________________________________________________________________________________

 

 

_______________________________________       _________________________________________

   (Signature of Reporting Staff Member)                            (Signature of Principal)

                                                                                                      

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Administrative Procedure 315 - Form 315-4

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January, 2011