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  • Accident-Incident Report

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    This document is an accident/incident report form for Whiteville City Schools in Whiteville, North Carolina. The form collects information about accidents or incidents involving students or staff, including the name, age, and grade of the student; date and time of injury; location and nature of injury; details of the accident; actions taken; whether parents and EMS were notified; and signatures of witnesses, the nurse, and principal. The purpose is to document any accidents or medical incidents occurring at the schools.

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    accident-incident report

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    This document is an accident/incident report form for Whiteville City Schools in Whiteville, North Carolina. The form collects information about accidents or incidents involving students or staff, including the name, age, and grade of the student; date and time of injury; location and nature of injury; details of the accident; actions taken; whether parents and EMS were notified; and signatures of witnesses, the nurse, and principal. The purpose is to document any accidents or medical incidents occurring at the schools.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    27 views1 page

    Accident-Incident Report

    Uploaded by

    api-244351020
    This document is an accident/incident report form for Whiteville City Schools in Whiteville, North Carolina. The form collects information about accidents or incidents involving students or staff, including the name, age, and grade of the student; date and time of injury; location and nature of injury; details of the accident; actions taken; whether parents and EMS were notified; and signatures of witnesses, the nurse, and principal. The purpose is to document any accidents or medical incidents occurring at the schools.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Whiteville(City(Schools(

    PO(Box(609(
    107(W.(Walter(Street(

    Whiteville,(NC(28472!
    !
    Accident/Incident!Report!
    !
    !
    Name!of!Student/Staff!____________________________!!Age___!Date!of!Birth!__________!
    !
    Sex!_____!!!!!!!!!!!!!!!!!!If!Student!;!Grade__________!Teacher____________________!!
    !
    School!_______________________!Date!of!Injury__________!Time!of!Injury__________!!
    !
    First!Responder________________________________________________________!
    !
    !
    Place!of!Injury!! !!!!!!!!!!Nature!of!Injury!! !!!!!!!Body!Part!Injured! !

    !!!!!!Illness!

    !
    __Bus!! !

    !
    __Bruise!!!!!!!!!!!!!!!!!!!!!__Abdomen!!!__Eye!(L!or!R)!!!!!__Respiratory!!Emergency!(asthma)!
    __Classroom!!
    !
    __Scrape!!
    !!!!!!__Head!!!!!!!!!!__Leg!(L!or!R)!!!!!__Allergic!Reaction!
    __Hallway!!
    !
    __Choking!!
    !!!!!!__Face!!!!!!!!!!__Ear!(L!or!R)!!!!!__Heat!Related!illness!
    __Bathroom!!
    !
    __Bum! !
    !!!!!__!Back!!!!!!!!!!__Foot!!(L!or!R)!!!!__Diabetic!Emergency!
    __Cafeteria!!
    !
    __Fracture/Sprain!!!!!!__Buttocks!!!!!__Hand!(L!or!R)!!!__!Other!
    __Playground!! !
    __Head!injury!! !!!!!!__Chest!!!!!!!!!__Arm!(L!or!R)!
    __Gymnasium!! !
    __Laceration/Cut!!!!!!!!__Nose!!!!!!!!!!__Knee!(L!or!R)!
    __Multipurpose!Room!!!!!!!!__Medication!Error!!!!!__Dental!!!!!!!!!__Wrist!!(L!or!R)!

    __Athletic!Field!!!!!!!!!!!!!!__!Other!
    __Other!____________!
    !
    !
    Describe!details!of!accident/incident!______________________________________________________!
    !
    ____________________________________________________________________________________!
    !
    Describe!action!taken__________________________________________________________________!
    !
    ___________________________________________________________________________________!
    !
    Were!parents!notified?!__Yes!__No!!!!!Person!contacted!__________________By!whom!________!

    !
    Was!EMS!called!___Yes!___!No!

    !
    If!head!injury!occurred,!was!Head!Injury!Sheet!sent!home?!!___!Yes!___No!___!N/A!
    !
    Was!completed!Accident/incident!Report!sent!home?!___!Yes!____No!
    !
    Was!student/staff!member!seen!by!doctor?!___Yes!___No!
    !
    !
    _________________________!!!_________________________!!!_______________________________!
    Signature!of!Witness!and!Date! !!!!!!!!!!!!Nurse!and!Date! !!!!!!!!!!!!!!!!!!!!!Principal!and!Date!
    !
    !

    When(completed(please(turn(in(form(to(the(School(Nurse.!
    !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Rev.!8/2014!!!!!!!!!!!!!!!!!!!!!!!!!

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