Student/Employee Name DOB Grade NAK123456789101112
Date and Time of Injury Body Part Injured
Location (Building/Room) Where Injury Occurred
Was the Injury Witnessed? Yes No By Whom?
Explain Details of Injury (how injury occurred and anyone involved)
What First Aid Was Provided? NoneIceSplintingAce WrapWound CleansedBandageDirect Pressure Press Ctl key to select more than one option.
Other First Aid
Was Parent/Guardian Notified? Yes No Who?
Was EMS Called? Yes No Was the Nursing Staff Notified? Yes No
The Student/Employee Went: to the Nurseto the doctorback to classback to practicehome withother Home with or other
Reporting Person Date/Time
This section to be completed by nursing staff.
Reviewed by Date/Time
Follow up needed? Yes No
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