BYRON-BERGEN CENTRAL SCHOOL 6917 West Bergen Road Bergen, NY 14416-9747 (585) 494-1220
Fax Number (585) 494-2613

Accident/Incident Report Form

____________________________was injured on ____________ DOB ____________ Grade ___ (Print Student/Staff Name)	(date and time)

PLACE WHERE INJURY OCCURRED:	BODY INJURY SITE:
qHome School	qLocker Area	qHead	qEar	qEye	qNose qAway School	qPhys. Ed. Class	qMouth	qTooth	qJaw	qNeck qField/Court	qPlayground	qChest	qRib	qBack	qAbdomen qBus                                                            qGenitals	qExtremity (specify below)
qOther ___________________________		qLeft	qRight Upper                                 Lower
ACTIVITY: _______________________________	qShoulder	qHip SPORT: _________________________________	qArm	qThigh qVarsity	qGirls	qElbow	qKnee qJunior Varsity	qBoys	qHand	qShin qModified	qCo-Ed	qWrist	qAnkle
qFinger #___	qFoot TYPE OF INJURY:	(thumb, #1, pinky #5)	qToe
qFall	qAltercation	(big toe #1, baby toe #5) qCollision	qHuman Bite
qOther (specify): _________________________

OBSERVATIONS/COMMENTS: _______________________________________________________

WAS THERE A TRANSER OF BLOOD OR BODY FLUID? qYes qNo
(IF “YES”IS INDICATED, PARENTS/STAFF MEMBER MUST CONTACT THEIR PRIVATE PHYSICIAN TODAY TO DISCUSS NEED FOR FURTHER CARE.)

FIRST AID RENDERED:

qNone	qCleaned & Bandaged	qElastic Bandage	qIce	qReturned to Class qRest & return to play/activity	qRest & restricted from further play/activity
qOther (specify): ________________________________________________________________

INDIVIDUAL WAS DISCHARGED:

qHome on regular bus/car	qTransported by ambulance to hospital

qPicked up by parent/guardian	qOther (specify): ______________________________ qFamily/Parents notified	qMethod of Notification (specify): _________________ Recommendation(s) to Individual/Parent/Student: _____________________________________

ACTION OR RECOMMENDATION (TO PREVENT FUTURE ACCIDENT/INCIDENT): ______________________ ______________________________________________________________________________

THIS FORM WAS COMPLETED BY THE SUPERVISING STAFF MEMBER WHO IS NOT A PHYSICIAN.

Signature/Date: ______________________ Principal Signature/Date: ______________________

SCHOOL NURSE FOLLOW-UP

Comments: _____________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

Signature/date ___________________________________

cc:	School Nurse (original), Athletic Director, Athletic Trainer, Business Office