SAMPLE

XYZ Charter

719 Fourth Street

Anytown, TX

555/555-1234

Interoffice School Accident Report

Student Name __________________________________ Date ________________________

Address ____________________________________________________________________

City ______________________________ State ___________________ Zip _____________

Grade _____________ Home Phone ____________________________ Age_____________

Description of Accident _______________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Description of Injury __________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Name of adult(s) present at time of accident_________________________________________________

First Aid given and by whom______________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Response to treatment_________________________________________________________

We could/could not (circle one) reach you by phone.

Name of Parent/Guardian notified __________________________ Time ________________

Disposition of Student:

_____ 1. Sent home ______ 4. Sent to a hospital by private car

_____ 2. Returned to class ______ 5. Called 911

_____ 3. Sent to doctor

Administrator Signature ___________________________________ Date _______________

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