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Accident/Incident Report
Information Regarding Individual Involved In Incident
Involved person's relationship to Seton High School:
*
Student
Employee
Visitor
First Name
*
Last Name
*
Date of Birth
*
Street Address
City
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
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Montana
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New Hampshire
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New York
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Ohio
Oklahoma
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Pennsylvania
Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Zip
Cell #
Parent/Guardian 1 First Name
Parent/Guardian 1 Last Name
Parent Cell
Email
Documentation of Accident/Incident
Date accident/incident occurred
Time
Hours
Minutes
AM/PM
AM
PM
Place incident/accident occurred
Supervising teacher(s)
Describe how the accident/incident occurred
Describe the location (area of body) and nature of the injury/illness
Was anyone else involved?
Yes
No
Who else was involved?
Explanation of involvement
Witness(es)
Action Taken
First aid given?
Yes
No
By whom?
Emergency Medical System (911) notified?
Yes
No
Time 911 was notified
Hours
Minutes
AM/PM
AM
PM
Parent/Guardian/Family member notified?
Yes
No
Time family was notified
Hours
Minutes
AM/PM
AM
PM
Reason family was NOT notified?
Principal notified?
Yes
No
Time principal was notified
Hours
Minutes
AM/PM
AM
PM
Other(s) notified?
Yes
No
Time others were notified
Hours
Minutes
AM/PM
AM
PM
Victim was sent
Home
Physician
Emergency Room
Time sent
Hours
Minutes
AM/PM
AM
PM
Accompanied by?
Name of physician
Hospital visited
Follow-up needed
Name of person completing form
Title
Email address
Date
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