Incident Report

I. Personal Data
Injured Person's Name: Date of Birth:
( Last Name ) (First Name ) (Middle Name)

Grade and Section:

Address:

Students Contact Number:

Parents /Guardian

Mother: Father:

Guardians Contact Number:

II. Details of Illness/Incident

Incident Date: Incident Time(approximate):

Location of Incident: Adviser:

Name(s) of persons involved:
Subject Teacher:

School Clinician:
Description of events leading up to incident:

Type of injury:

First Aid Given:

Does Injury require Hospitalization/ Physcian? Yes □ No □

Hospital Name:
Hospital Procedure done or required medical test:

Description of conversation with the injured party, the students involved and the school action regarding the incident.

Further Recommended Care

Prepared By : Date Accomplished:

Kindly attached any necessary evidence to support statements

Kindly attached any necessary evidence to support statements