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2017-2018 Athletic Injury Report

Please fill out the form using the following guidelines:

1. Demographic Information

2. Parent/Guardian must be notified at the time of the accident. Note date/time/and how the parent was notified (phone/in Person), and who notified them.

3. Date accident occurred and date the accident is reported to the nurse/administration.

4. Location of accident.

5. Describe the injury. Write down what you see. Example - Bruise, swelling, bleeding, bone sticking out of skin, etc. DO NOT diagnose injury. Example - Do not put down sprain, strain, or fracture. Indicate what body part(s) is injured. Example - Ankle injury, knee injury.

6. What was the cause of the accident? How did the accident occur? Any witnesses? Anyone else involved?

7. Supervisor at the time of the accident? Who was in charge?

8. First aid provided. Who provided care (coach, EMT, doctor, trainer, nurse)? Disposition of case. Example - Student left with parent to see own doctor. Student transported to emergency room (which one) via ambulance.


Any student, who is injured and seeks medical treatment of any kind, must have a written order from their doctor indicating clearance to resume participation.

Accident Injury Report - February 2, 2018 to June 30, 2018
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