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Accident/Injuries to Student Form
12/12/2016

Jefferson County School System

Report Of Accidents And Injuries To Students

 

 

Name: ____________________________________     Date of Birth: ______________________

 

School:          Piedmont Elementary School                  Grade Level: ______________________

 

Parent/Guardian: _______________________________________________________________

 

Mailing Address: _______________________________________________________________

 

Phone Numbers: _______________________________________________________________

                                                   (home)                                               (work)                                                 (cell)

Date of Injury: _______ Exact Time: _______ Location of Injury: ________________________          

 

What activity was involved at time of injury? _________________________________________

 

______________________________________________________________________________

                                                                                                                                                           

Part of body injured (indicate L/R): _________________________________________________

 

______________________________________________________________________________

 

Description of Injury: ____________________________________________________________

 

______________________________________________________________________________

 

How did accident occur? __________________________________________________________

 

______________________________________________________________________________

 

Describe action that was taken following accident: _____________________________________

 

______________________________________________________________________________

 

Does injured have school insurance?   ____ Yes     ____ No

Disposition made of case-

Insurance report made: ___________________________     Date filed:  _____ _______________

 

Reported to parent/guardian: ______________________   Date reported: ______ ____________

 

 

                                                                                                                                                           

 

____________________________________    ____________________________________

         Signature of Person Filing Report                                    Date of Report

 

 

NOTE: Report should be filed with the Director of Schools as early as possible.

Complete in Triplicate:   ___ TEA

                                       ___ Director of Schools

                                      ___School’s Copy