568E1 - Student Illness or Injury at School Accident Report Form

Date and Time of Incident:

 

Location of Incident:

 

Parent’s/Guardian’s Phone Number:

 

Alternate Parent’s/Guardian’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