INJURY

    REPORT
    EVERETT PUBLIC SCHOOLS P.O. BOX 2098 EVERETT, WA 98213

    STUDENT/CITIZEN ~ INCIDENT/ACCIDENT REPORT FORM

    THIS FORM DOES NOT COMPLY WITH RCW 4.96.020 FOR THE FILING OF A CLAIM FOR DAMAGES
    FORM INSTRUCTIONS:   This form to be completed by DISTRICT PERSONNEL ONLY any time a student or person other than an employee is injured on Everett Public Schools property. Do not allow student or parents/injured party to complete. Do not use this form to report employee (on the job) injuries. Complete and forward this form to the Finance Department, Risk Manager within 24 hours of the incident. If an accident occurs that is critical in nature, please call the Finance Department, Risk Manager at 425-385-4150 and report the accident verbally. Describe the incident in sufficient detail to show the conditions that existed at the time of the incident.
    GENERAL INFORMATION             SCHOOL DISTRICT: Everett Public Schools  SCHOOL NAME:      
    DISTRICT CONTACT: Jeff Moore or Kim Walker PHONE NUMBER: 425-385-4150
    INCIDENT/ACCIDENT DATE:       TIME:       AM PM      
    LOCATION:   CLASSROOM PLAYGROUND GYM LABORATORY SHOP OFF-PREMISES OTHER, SPECIFY:      
    DESCRIPTION OF ACCIDENT/CAUSE OF INJURY:      
         
    WITNESS(ES):       PHONE NUMBER:      
    WITNESS(ES):       PHONE NUMBER:      
    IDENTIFY AGENCY CALLED TO SCENE (police, fire, etc):       REPORT NUMBER:      
    INJURIES (complete separate form for each injured individual)  FOR EMPLOYEE INJURIES – CONTACT HUMAN RESOURCES AT 425-385-4115
    NAME:                     STUDENT CITIZEN  
    LAST FIRST MI   
    ADDRESS:                   GENDER:   AGE:    GRADE:   
    STREET CITY ZIP CODE   
    NAME OF PARENT/GUARDIAN (if applicable):       HOME PHONE:      
    ADDRESS OF PARENT:       WORK PHONE:      
    PART OF BODY INJURED:       TYPE OF INJURY (e.g., cut, burn):       CELL PHONE:      
    EXTENT OF INJURY (e.g., minor, severe):       NO. OF SCHOOL DAYS LOST:      
    IF CITIZEN, REASON FOR BEING AT SCHOOL/FACILITY:      
    PERSON IN CHARGE AT TIME OF INCIDENT:       TITLE:       PHONE #:      
    ACTION TAKEN:      
    BY WHOM/WHEN:       PRESENT AT SCENE? ð YES ð NO
    SENT TO HEALTH ROOM SENT HOME 911 CALLED SENT TO HOSPITAL/DOCTOR IF STUDENT, ACCIDENT. INS? YES NO
    STUDENT FELT WELL AND RETURNED TO CLASS AFTER      _ MINUTES OF OBSERVATION
    ADDITIONAL INJURY INFORMATION:
    PARENT/GUARDIAN NOTIFIED:       PHONE #:      
    WHEN NOTIFIED:       BY WHOM:      
    BUMPS OR BLOWS TO THE HEAD - SYMPTOMS:
    SLIGHT HEADACHE MINOR ABRASION/CUT PALENESS OR FLUSHING WEAKNESS OR PARALYSIS
    NAUSEA/VOMITING CONFUSION/INCOHERENT BRUISING/SORE LOSS OF CONSCIOUSNESS
    LOSS OF MEMORY DIZZINESS VISION CHANGES SWELLING AT INJURY SITE
    BUMPS OR BLOWS TO THE HEAD - TREATMENT:   
    ICE APPLIED BANDAGE APPLIED OTHER (comment):      
    REPORT PREPARED BY:       TITLE:      
    SIGNATURE:  DATE:      
    BLDG. ADMINISTRATOR SIGNATURE:  DATE:      
    FOR FINANCE USE ONLY DATE LOGGED:  DATE SENT TO RISK POOL:   

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      PLEASE SEND THE ORIGINAL TO FINANCE AND KEEP A COPY FOR YOUR RECORDS REV. 06/04