Incident Report

Student Name *

First Name

Last Name

Student Date of Birth *

MM

DD

YYYY

Date of Incident *

MM

DD

YYYY

Time of Incident *

Hour

Minute

Second

AM PM

Parent/Guardian Name *

First Name

Last Name

Parent/Guardian Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Cell Phone *

(###)

###

####

Parent/Guardian Work Phone

(###)

###

####

Parent/Guardian Home Phone

(###)

###

####

Surface *

Check All That Apply

Asphalt

Carpet

Concrete

Dirt

Gravel

Gymnasium Floor

Ice/Snow

Lawn/Grass

Mat(s)

Sand

Synthetic Surface

Tile

Wood Chips/Mulch

Type of Injury *

Check All That Apply

Abrasion/Scrape

Bite

Bump/Swelling

Bruise

Burn/Scald

Cut/Laceration

Dislocation

Fracture

Pain/Tenderness

Puncture

Sprain

Other

Location of Injury *

Check All That Apply

Head

Eye

Ears

Nose

Mouth/Lips

Tongue/Teeth

Jaw

Chin

Neck/Throat

Collarbone

Shoulder

Upper Arm

Elbow

Forearm

Wrist

Hand

Finger

Fingernail

Chest/Ribs

Back

Abdomen

Groin

Genetals

Pelvis/Hip

Leg

Knee

Ankle

Foot

Toe

Response *

Returned to Class

Sent/Taken Home