Oregon Episcopal School

ACCIDENT/INCIDENT REPORT FORM

This form should be filled out and filed within 5 days of an accident/incident that occurs at OES or as part of an OES program.

Completed forms should be filed with the School Nurse. Use back of form if necessary.

Name of class, activity or trip: *

Date of Incident * +

Time of incident: *

First Name of injured party *

Last Name of injured party *

Grade:

Name of person filling out this form? *

Were they: *

Employee

Student

Other Other

Student Type: *

Boarding

Day

Was this OES sports related injury? *

Yes

No

Adult supervising (if any):

List all faculty/staff/parents/others who aided in the response:

Activity at time of accident/incident (be specific): *

Accident/Incident location: *

Narrative: Describe in detail what happened. Include any factors which contributed to the incident, e.g. darkness, fatigue, slick surface, etc *

Part of body injured and type of injury: *

Was first aid administered? *

Yes

No

By Whom: *

Describe care given: *

At what time did a parent assume responsibility for the student?