4:170-AP1, E1, Accident or Injury Form
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
| Name | Address | Telephone |
First aid administered? Yes No
If yes, describe first aid administered and by whom:
Supervisor (please print)
Signature Date
Date Adopted: October 25, 2022
