Please complete and submit to school nurse

Name of insured:________________________________

Date:______________

Time of accident:_____________ Exact location:_____________________________

Staff person present:_______________________________________

Description of accident:

________________________________________________________________________________________________________________________________________________________________________________________________________________________

Description of injury:

Care given:______________________________________________________________

Was parent notified?___________ What advice was given?______________________ ________________________________________________________________________

Disposition: _____To hospital _____Home

_____Ambulance _____Health Office

_____Back to class

Signature:___________________________________

Nurse:______________________________________

Principal:_________________________________

****Nurse’s use only: Follow-up medical dx and rx, future prevention efforts, etc.