For access to the form, click here.
Policy EBBB-E
Name:_______________________________________ Date of Accident:__________ Time of Accident:____________
School:______________________________________ Grade:_____ Teacher:__________________
Witnesses:____________________________
Location: (check one)
playground playscape
gym/p.e. classroom (specify)
Hall
stairs
other (specify)
Description of Accident: _____________________________________________________________________________
__________________________________________________________________________________________________
OBSERVATION (check)
abrasion possible allergic reaction bruise/bump poss.fracture/sprain/strain burn
laceration/cut puncture loss of consciousness seizure other Other describe:
BODY PART INJURED (check)
head teeth back/spine genitals eye neck arm leg nose shoulder elbow
knee face abdomen hand ankle mouth chest finger foot buttock wrist toe
Action Taken
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Parent Notified:_____Yes_____No Nurse Notified:_____ Yes _____No
Nurse’s Assessment (when indicated):
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________
Date: Nurse’s Signature: ___________________________________________
Date: Principal’s Signature:_________________________________________
Follow-Up:
Original: File in Student Cumulative Record
Copy to: Director of Finance, HR & Operations
*Please excuse any formatting errors.
