STUDENT INJURY REPORT FORM

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Name of Injured Student

First Name

Last Name

Student ID#*

Was medical treatment required?*

Yes

Were you transported by EMS?

Yes

Public Safety Notified?*

Yes

Date and Time of Injury/Accident*

Date Injury Was Reported*

Emergency Contact Notified?

Yes

Name of Person Contacted

First Name*

Last Name*

Location of Incident

Part of Body Injured

Description of Accident

Are there any witnesses to the accident/incident? If yes, who?

Cause of Accident

Public Safety