The supervisory staff member must complete this form for submission to the Superintendent whenever any person, is injured on District property or at a District-sponsored event.

Name of injured person                                         

Date of Birth              Telephone                 

Address                                                 

Class, activity, or event                                         

Accident location                                         

Accident date                     Time of accident                     

How did the accident occur? (Describe sequence of events)                         

Emergency contact notified?   ☐ Yes   ☐ No  If no, explain why:                    

If yes, provide the following:

Contact name                         Relationship                 

Time and method of contact                 By whom                 

Witnesses Information

First aid administered?   ☐ Yes   ☐ No    

If yes, describe first aid administered and by whom:                            

Supervisor (please print)                             

Signature                             Date

UPDATED:    June 7, 2022