LLCA Incident/Accident/Injury Report

Please complete the form below. Required fields marked with an asterisk * Submit to the office as quickly as possible following the incident.

Name of Injured*

Answer required for "Name of Injured"

Age*

Answer required for "Age"

Grade*

Answer required for "Grade"

Teacher*

Answer required for "Teacher"

Gender*

Answer required for "Gender"

Please check all that apply.

Place of Injury*

Answer required for "Place of Injury"

Classroom number __________

Bathroom

Playground

Basketball Court

Car Pool Area

Other ___________________________________________________________________________________________

Nature of Injury*

Answer required for "Nature of Injury"

Abrasion

Asphyxia

Burn

Fracture/Sprain

Head Injury

Laceration

Other ____________________________________________________________________________________________

Give a complete description of the incident, accident, or injury (when, where, how, etc.)*

Answer required for "Give a complete description of the incident, accident, or injury (when, where, how, etc.)"

Were the parents/guardians notified?*

Answer required for "Were the parents/guardians notified?"

Yes

How were parent/guardians notified?*

Answer required for "How were parent/guardians notified?"

Was 911 involved?*

Answer required for "Was 911 involved?"

yes

Name of person contacting 911.

Answer required for "Name of person contacting 911."

Describe Treatment and Disposition*

Answer required for "Describe Treatment and Disposition"

Name of Person Reporting Incident*

Answer required for "Name of Person Reporting Incident"

Date of Incident*

Answer required for "Date of Incident"

Approximate Time of Incident*

Answer required for "Approximate Time of Incident"

Signature of School Director*

Signature Required

Be sure to send a copy to the School Nurse and to an Administrator

Date sent to Nurse and Administrator*

Answer required for "Date sent to Nurse and Administrator"

Please fix the highlighted areas below before submitting.

LLCA Incident/Accident/Injury Report