Report Accident Form
School Name
School Personnel Completing this Form
Date of Accident
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Calendar
Name of Student
Student ID#
Age
Grade
Parent/Guardian
Phone Number of Parent/Guardian
Address
Time of Accident
Witness(s) to Accident
Nature and Extent of Injury (if any)
How did the accident occur?
Where did the accident occur?
Action taken by school personnel?
My supervisor has been notified of this incident.
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Additional Notes
Date my supervisor was notified.
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Calendar
Supervisor's name
Student has been transported to a medical facility
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If yes, I have contacted the office of Dr. Duffy.
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Type of Accident Report:
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Adult's Name
Adult's Phone Number
Adult's Address
Adult has been transported to medical facility?
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