534.1 STUDENT ILLNESS OR INJURY AT SCHOOL ACCIDENT REPORT FORM

Date and Time of Incident:                                                                                                    

Location of Incident:                                                                                                              

Parent’s Phone Number:                                                                                                       

Alternate Parent’s Phone Number:                                                                                        

Name of Student:                                                                                                                  

Address of Student:                                                                                                               

Please write a brief description of what occurred:

Please list any eyewitnesses to what occurred (attach statements, if any, to this report):

Please indicate what procedure was taken to resolve the incident:

                                                                                    Signature

First Reading Approved  3/12/2018                                      Second Reading Approved 4/9/2018