STUDENT ILLNESS OR INJURY AT SCHOOL ACCIDENT REPORT FORM
Date and Time of Incident:
Location of Incident:
Parent’s Phone Number:
Alternate Parent’s Phone Number:
Name of Student:
Address of Student:
Please write a brief description of what occurred:
Please list any eyewitnesses to what occurred (attach statements, if any, to this report):
Please indicate what procedure was taken to resolve the incident:
Signature