Adopted: 

Revised:  02/17/1986, 12/07/1993, 02/19/2007                                               722.2 Exhibit

School District of Prairie Farm

Accident Report Form

In case of injury to a student, this report is to be completed by the supervisor in charge of the activity.

Student's name:

Last:___________________________ First:____________________ M.I.____________

Date of Birth:_________________________ Social Security #:_____________________

Sex:_______________ Grade:___________________

Student's home address:____________________________________________________

Date of Accident:

Month:___________________ Day:_______________ Year: 20_____

Hour:_______________  AM or PM

Detailed description of accident:  How did it occur?______________________________

________________________________________________________________________

________________________________________________________________________

Where did it occur? _______________________________________________________

________________________________________________________________________

Part of body injured:  Right________ Left__________ Part:_______________________

Activity:  Sport:_________________________ Interscholastic:_____________________

Intramural___________________ Other (describe):______________________________

Name of school authority supervising activity:__________________________________

Was supervisor a witness to the accident?  Yes____________ No_____________

If not, when was the accident first reported to a school authority?

Date:______________________________

Date of report:______________________________

Signature of Supervisor:_________________________________________________

Signature of Administrator:_______________________________________________