Student Accident Report Form Please complete the following form as completely and accurately as possible (essential fields are marked with a *). General Information Date Originated: Monday Jun 27, 2022 * Building: -- Please select -- Davey Holden Longcoy Walls Roosevelt Stanton Other *Your Name: *Room #/Area: *Your kentschools.net email address: *Student Name: Grade: Student ID: Student Birth Date: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Student Address: Student Phone: Accident Information *Date of Accident: Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 *Time of Accident: 12:00 AM 12:05 AM 12:10 AM 12:15 AM 12:20 AM 12:25 AM 12:30 AM 12:35 AM 12:40 AM 12:45 AM 12:50 AM 12:55 AM 1:00 AM 1:05 AM 1:10 AM 1:15 AM 1:20 AM 1:25 AM 1:30 AM 1:35 AM 1:40 AM 1:45 AM 1:50 AM 1:55 AM 2:00 AM 2:05 AM 2:10 AM 2:15 AM 2:20 AM 2:25 AM 2:30 AM 2:35 AM 2:40 AM 2:45 AM 2:50 AM 2:55 AM 3:00 AM 3:05 AM 3:10 AM 3:15 AM 3:20 AM 3:25 AM 3:30 AM 3:35 AM 3:40 AM 3:45 AM 3:50 AM 3:55 AM 4:00 AM 4:05 AM 4:10 AM 4:15 AM 4:20 AM 4:25 AM 4:30 AM 4:35 AM 4:40 AM 4:45 AM 4:50 AM 4:55 AM 5:00 AM 5:05 AM 5:10 AM 5:15 AM 5:20 AM 5:25 AM 5:30 AM 5:35 AM 5:40 AM 5:45 AM 5:50 AM 5:55 AM 6:00 AM 6:05 AM 6:10 AM 6:15 AM 6:20 AM 6:25 AM 6:30 AM 6:35 AM 6:40 AM 6:45 AM 6:50 AM 6:55 AM 7:00 AM 7:05 AM 7:10 AM 7:15 AM 7:20 AM 7:25 AM 7:30 AM 7:35 AM 7:40 AM 7:45 AM 7:50 AM 7:55 AM 8:00 AM 8:05 AM 8:10 AM 8:15 AM 8:20 AM 8:25 AM 8:30 AM 8:35 AM 8:40 AM 8:45 AM 8:50 AM 8:55 AM 9:00 AM 9:05 AM 9:10 AM 9:15 AM 9:20 AM 9:25 AM 9:30 AM 9:35 AM 9:40 AM 9:45 AM 9:50 AM 9:55 AM 10:00 AM 10:05 AM 10:10 AM 10:15 AM 10:20 AM 10:25 AM 10:30 AM 10:35 AM 10:40 AM 10:45 AM 10:50 AM 10:55 AM 11:00 AM 11:05 AM 11:10 AM 11:15 AM 11:20 AM 11:25 AM 11:30 AM 11:35 AM 11:40 AM 11:45 AM 11:50 AM 11:55 AM 12:00 PM 12:05 PM 12:10 PM 12:15 PM 12:20 PM 12:25 PM 12:30 PM 12:35 PM 12:40 PM 12:45 PM 12:50 PM 12:55 PM 1:00 PM 1:05 PM 1:10 PM 1:15 PM 1:20 PM 1:25 PM 1:30 PM 1:35 PM 1:40 PM 1:45 PM 1:50 PM 1:55 PM 2:00 PM 2:05 PM 2:10 PM 2:15 PM 2:20 PM 2:25 PM 2:30 PM 2:35 PM 2:40 PM 2:45 PM 2:50 PM 2:55 PM 3:00 PM 3:05 PM 3:10 PM 3:15 PM 3:20 PM 3:25 PM 3:30 PM 3:35 PM 3:40 PM 3:45 PM 3:50 PM 3:55 PM 4:00 PM 4:05 PM 4:10 PM 4:15 PM 4:20 PM 4:25 PM 4:30 PM 4:35 PM 4:40 PM 4:45 PM 4:50 PM 4:55 PM 5:00 PM 5:05 PM 5:10 PM 5:15 PM 5:20 PM 5:25 PM 5:30 PM 5:35 PM 5:40 PM 5:45 PM 5:50 PM 5:55 PM 6:00 PM 6:05 PM 6:10 PM 6:15 PM 6:20 PM 6:25 PM 6:30 PM 6:35 PM 6:40 PM 6:45 PM 6:50 PM 6:55 PM 7:00 PM 7:05 PM 7:10 PM 7:15 PM 7:20 PM 7:25 PM 7:30 PM 7:35 PM 7:40 PM 7:45 PM 7:50 PM 7:55 PM 8:00 PM 8:05 PM 8:10 PM 8:15 PM 8:20 PM 8:25 PM 8:30 PM 8:35 PM 8:40 PM 8:45 PM 8:50 PM 8:55 PM 9:00 PM 9:05 PM 9:10 PM 9:15 PM 9:20 PM 9:25 PM 9:30 PM 9:35 PM 9:40 PM 9:45 PM 9:50 PM 9:55 PM 10:00 PM 10:05 PM 10:10 PM 10:15 PM 10:20 PM 10:25 PM 10:30 PM 10:35 PM 10:40 PM 10:45 PM 10:50 PM 10:55 PM 11:00 PM 11:05 PM 11:10 PM 11:15 PM 11:20 PM 11:25 PM 11:30 PM 11:35 PM 11:40 PM 11:45 PM 11:50 PM 11:55 PM *Supervised Activity? Yes No If 'yes', person in charge: *Nature of Injury Abrasion/Bruise Laceration/Cut Possible Fracture Animal Bite Possible Concussion Nose Bleed Possible Dislocation Insect Bite Burn Possible Sprain Puncture Chipped Tooth Possible Strain Illness Other: *Location of Injury Head Scalp Back Front Temple (Left) Temple (Right) Eyes (Left) Eyes (Right) Ears (Left) Ears (Right) Nose Mouth Tooth Neck Trunk Chest Abdomen Back Arms Shoulder (Left) Shoulder (Right) Upper Arm (Left) Upper Arm (Right) Elbow (Left) Elbow (Right) Lower Arm (Left) Lower Arm (Right) Hand (Left) Hand (Right) Wrist (Left) Wrist (Right) Finger/Thumb Legs Hip (Left) Hip (Right) Thigh (Left) Thigh (Right) Knee (Left) Knee (Right) Lower Leg (Left) Lower Leg (Right) Foot (Left) Foot (Right) Ankle (Left) Ankle (Right) Toe *Where Accident Happened * Building where incident occurred: -- Please select -- Davey Holden Longcoy Walls Roosevelt Stanton Other Other (please note below) Athletic Field Cafeteria Classroom To/From School Auditorium/Stage Hallway Playground (see below) Restroom School Bus Shower/Dressing Room Shop/Labs Stairway Gym Outdoors Other: Playground Related Active Game Collision with student Collision with equipment Fall from equipment Weather related Fighting Horseplay Running Other: Accident Description *Brief description of accident: Action Taken *Was first aid given? Yes No If 'yes', by whom: Describe injury and treatment: *Was parent or other designated person notified? Yes No Name of person notified & relationship to student: Time notified: Student was sent to: -- Please select -- Class Home Doctor Held in Clinic Hospital Other: If sent to 'Other': Student transported by: -- Please select -- Parent Ambulance Neighbor Relative Self Other: If transported by 'Other':