The supervisory staff member must complete this form for submission to the Superintendent whenever any person is injured on District property or at a District-sponsored event.
Name of injured person
Date of Birth Telephone
Address _ __
Class, activity, or event _
Accident location _
Accident date Time of accident _
How did the accident occur? (Describe sequence of events)
Emergency contact notified? Yes No If no, explain why:
If yes, provide the following:
Contact name Relationship
Time and method of contact By whom
Witnesses Information
Name
Address
Telephone
First aid administered? Yes No
If yes, describe first aid administered and by whom:
Supervisor (please print)
Signature Date
Date Adopted: October 25, 2022
The supervisory staff member must complete this form for submission to the Superintendent whenever any person is injured on District property or at a District-sponsored event.
Name of injured person
Date of Birth Telephone
Email _________________________________
Address
Class, activity, or event
Accident location
Accident date Time of accident
How did the accident occur? (Describe sequence of events)
Emergency contact notified? Yes No If no, explain why:
If yes, provide the following:
Contact name Relationship
Time and method of contact By whom
Witnesses Information
Name
Address
Telephone
Email
First aid administered? Yes No (please explain):
If yes, describe first aid administered and by whom:
Supervisor (please print)
Supervisor Signature Date
Date Adopted: October 25, 2022
The supervisory staff member must complete this form for submission to the Superintendent whenever any person is injured on District property or at a District-sponsored event.
Name of injured person
Date of Birth Telephone
Email _________________________________
Address _ __
Class, activity, or event _
Accident location _
Accident date Time of accident _
How did the accident occur? (Describe sequence of events)
Emergency contact notified? Yes No If no, explain why:
If yes, provide the following:
Contact name Relationship
Time and method of contact By whom
Witnesses Information
Name
Address
Telephone
Email
First aid administered? Yes No(please explain):
If yes, describe first aid administered and by whom:
