Union Star R-II School District

1) Please specify below the date and time of the accident.

2) Name of Injured Student:

3) Who was the supervising adult?

4) Place where accident occurred:

5) Description of injury:

6) Was first aid administered?

Yes

No

7) Who was the person giving First Aid:

8) Please provide a description of the accident:

9) Mark appropriate information:

Inter-scholastic sports

Yes - Go to question 10

No - Go to question 12

10) Name of Sport:

Please type the name of the sport in which the accident occurred. Then go to question 11 and mark the appropriate answer.

11) Please mark the appropriate response below.

Practice

Game

Travel

Other - Please type your response in question 13.

12) Please mark the appropriate response below.

Non-Inter scholastic sports

Travel to/from school

In classroom

Physical Education class

On school grounds

Non-school activity

At home

Other - Please type your answer in question 13.

13) If you checked "other" in questions 11 or 12, please specify your answer below. (optional)

14) Were parents notified?

Yes

No

15) Date filed in the Principal’s office:

16) Signature of person making report: Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

17) Signature of Principal: Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

Elementary