Athletic Forms

WOODSTOCK ACADEMY
ACCIDENT REPORT FORM

A. NAME___________________________________  Grade_______  Date of  Report____________

                                                                                                        Date/Time of Injury____________

B.  NATURE OF INCIDENT/INJURY

      ___abrasion                ___amputation          ___bite                  ___breathing            ___bruise
      ___burn                       ___dislocation          ___electric shock   ___foreign body        ___fracture
      ___lacerations/cuts   ___poisoning             ___puncture            ___scratches            
      ___sprain/strain         ___other (specify)____________________________________________

C.  PART OF BODY INVOLVED, LEFT OR RIGHT
      ___abdomen         ___ankle                     ___arm                       ___back/neck        ___chest/rib
      ___ear                   ___elbow                     ___eye                      ___face             ___finger/thumb
      ___foot/toes          ___hand                      ___head                      ___hip                  ___knee
      ___leg                   ___mouth                    ___nose                      ___shoulder           ___tooth
      ___wrist                ___other (specify)_______________________________________________

D.  BUILDING / LOCATION
      ___athletic field    ___auditorium            ___bus                        ___cafeteria          ___classroom
      ___corridor/hall    ___gymnasium           ___home ec.               ___kitchen            ___laboratory
      ___locker              ___locker room          ___restroom               ___school grounds  ___shop
      ___stairs               ___to/from school       ___field trip              ___other (specify)____________

E.  ACTIVITY
     What activity__________________________________Phys Ed___________________________
     Sport__________________________    Game/Practice_________________________________

F.  DESCRIPTION OF ACCIDENT
     1.  How did accident occur________________________________________________________

     2.  Describe the injury ___________________________________________________________

3.  First Aid treatment? _____________________________________________________________

4.  Parent/other notified___________________________Time_________By Whom____________5. Was trainer notified  ___yes  ___ no

6. Was student evaluated by trainer ___yes  ___no   If yes, outcome:______________________

G.  ACTION TAKEN AND FOLLOW-UP
      ____Return to class/activity     ____ Sent home   ____Physician_________________________
      Follow-up report_______________________________________________________________

H.  PERSON COMPLETING REPORT (Coach/Trainer)
      Name ________________________Title____________________Date signed______________
I.  WITNESS_______________________________________________________________________