Student Injury Report

Student Injury Report
If you were injured on school property or during a school sponsored event, no matter how slightly, please report the incident immediately to a staff member and complete this form.

Important note: Claims for insurance compensation must be filled out within 10 days of the injury and submitted to Human Resources.
Student Name

FirstLast
Student ID Number
Grade Level
Date and Time of Injury

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
At what location did the injury take place?
Softball field, stairs in the FFC, etc.
What side of the body is the injury?
Location of injury on the body?
ankle, lower back, shoulder, etc.
Who was supervising?
Did the supervisor witness the injury?
Was this injury sport related?
Which sport?
Did anyone else witness the injury?

Yes (please list other witnesses)
Describe in detail the situation in which the injury occurred.
Did you see a physician?
Physician
Physician's Phone Number
Format: (000) 000-0000.
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hospital or Emergency Facility
Your Name (Form Submitter)
Your Email
A confirmation email will be sent to this address.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearField is auto-filled. No action needed.
Should be Empty: