Student Incident Investigation Report

Student Incident Investigation Report Please PRINT NEATLY EAST BATON ROUGE PARISH SCHOOL SYSTEM using a black or blue P.O. Box 2950 Baton Rouge, LA 70821 (225) 226-3468/69 ballpoint pen. ! Press hard !

Student Name as it appears on cumulative folder ______DATE OF INCIDENT DATE OF REPORT TIME OF INCIDENT # Days Lost GRADE SEX DATE OF BIRTH

School Name Student SS Number Student=s Address, City, State and Zip

Name of Parent or Legal Guardian: Parent=s Telephone Number: Names of Witnesses:

Parents notified by: Parent or other authorized person,  Telephone,  Note sent home,  Unable to contact parents. appeared at school in person to transport student Yes No Use the laminated code list provided. Code list also appears in the Appendix of the Risk Management Plan. If no code exists to cover the incident, provide a brief description under OTHER and details under #22. 10. Kind of Injury Code: Other 16. Immediate Code: Other: Action Taken 11. Cause of Injury Code: Other: 17. Location of Code: Other: Incident 12. Causative Agent Code: Other: 18. Activity of Code: Other: Person 13. Part of Body injured Code: Other: 19. Unsafe Act Code: Other:

14. Degree of Injury Code: Other: 20. Unsafe Code: Other: Condition 15. Supervision Code: Other: 21. Personal Code: Other: Factor

22. Describe the incident: Include a diagram on the back if needed. Photographs:  Yes,  No

23. Number of other students likely to be exposed 24. Frequency of possible future to a similar occurrence: occurrence of this incident: X Daily, X Weekly X Monthly  None

25. Action taken to prevent a reoccurrence:  Review w/ Students,  Special faculty safety meeting,  Discuss at next faculty meeting.

______26. Person who will conduct remediation as per #25. 27. Work Order number  Work Order copy attached. to correct unsafe condition: 28. Recommendations to other schools to avoid similar incidents:

29. Property damaged, if any:

30. Additional assistance requested from:  Risk Management,  Executive Director,  Security,  School Nurse,  Other

Investigated by: Principal=s Signature:

Revision date: 05/05 Original - Risk Management within 24 hours. Copy - School 10. KIND OF INJURY 14. Foot 18. ACTIVITY 1. Amputation MACHINERY 15. Other VARSITY ATHLETICS 2. Asphyxiation 34. Buffer 1. Archery 3. Bite 35. Grinder 14.DEGREE OF INJURY 2. Baseball 4. Bruise 36. Jointer 1. Death 3. Football 5. Burns/scalds 37. Lathe 2. Permanent impairment 4. Basketball 6. Concussion 38. Lawn mower 3. Temporary disability 5. Golf 7. Cuts 39. Planer 4. Non-disabling 6. Gymnastics 8. Dislocation 40. Band saw 7. Softball 9. Drowning 41. Circular saw 15. SUPERVISION 8. Tennis 10. Electrical shock 42. Jig saw 1. Classroom teacher 9. Track & Field 11. Foreign body 43. Sewing machine 2. P.E. teacher 10. Volleyball 12. Fracture 44. Vise 3. Teacher=s aide 11. Wrestling 13. Poisoning 45. Other 4. Principal/Administrator 12. Other 14. Sprain/Strain 5. Secretary/Clerk 15. Teeth damaged MATERIALS & EQUIPMENT 6. Volunteer PHYSICAL EDUCATION 16. Internal injuries 46. Athletic equipment ** 7. Bus driver 13. Badminton 17. Multiple injuries 47. Baseball, football, 8. Other 14. Basketball 18. Other basketball 9. None present 15. Football 48. Biological substances 16. Golf 11. CAUSE OF INJURY 49. Chemical substances 17. Gymnastics 50. Fence or wall 16.IMMEDIATE ACTION 1. Struck against 1. First aid 18. Dance 2. Struck by 51. Firearm 19. Rope skipping 52. Flammable material 2. First aid, sent home on bus 3. Fall from elevation 3. First aid, parent pick up 20. Soccer 4. Slip, trip or fall, same level 53. Furniture 21. Softball 54. Glass and glassware 4. First aid, EMS to hospital 5. Caught in, on or between 5. First aid, School Transported 22. Tennis 6. Body reaction 55. Hot liquid 23. Track & Field 56. Kitchen equipment 24. Volleyball 7. Overexertion 17. INCIDENT LOCATION 8. Contact with electricity 57. Kitchen utensil 25. Soccer 58. Kiln, oven SHOPS AND LABS 9. Contact with chemicals 1. Agriculture 59. Ladder, bench, stool MISCELLANEOUS 10. Contact with temp. extreme 2. Home Economics 60. Personal Prot. Equip. 26. Acting, concert 11. Other 3. Science 61. Pole or rod 27. Cleaning, repairing 4. Driver=s Ed (Practice) 12. CAUSATIVE AGENT 62. Paint, lacquer or spray 28. Conducting experiments 5. Driver=s Ed (Simulator) ANIMALS 63. Surfaces: floor, steps etc 29. Using tools 6. Vocational, industrial arts 1. Dog, cat 64. Windows, doors 30. Using machinery 7. ROTC 2. Horse, cow 65. Wood, lumber 31. At play 8. Other lab 3. Insect 66. Other 32. Running 9. Other shop 4. Snake 33. Walking 5. Other VEHICLES 34. Sitting 67. School bus BUILDING - GENERAL 35. Other 10. Auditorium APPARATUS 68. System car, truck, van 11. Theater stage 6. Balance beam 69. Commercial carrier 19. UNSAFE ACT 12. Band hall/choral room 7. Horizontal bar 70. Private car, truck, van 1. Horseplay 13. Classroom 8. Horizontal ladder 71. Aircraft 2. Fighting 14. Cafeteria 9. Pommel Horse 72. Leased vehicle 3. Disabled safety guard 15. Corridor 10. Low or turning bar 73. Skateboard 4. Using damaged tools 16. Locker room, showers 11. Carousel 5. Improper use of tools 17. Gymnasium 12. Jungle gym PERSONS 6. Did not use Pers Prot Equip 18. Stairway 13. Parallel bars 74. System employee 7. Overexertion 19. Restroom 14. Rings 75. Other student 8. Unauthorized use of tools 15. Rope 76. Parent or relative 9. Excessive speed GROUNDS 16. Slide 77. Third party 10. Improper position 20. Playground 17. Swing 11. Other MISCELLANEOUS 21. Football/soccer field 18. Teeter totter 20.UNSAFE CONDITION 78. Toys, etc. 22. Baseball field 19. Trampoline 1. Lack of training 79. Other 23. Track 20. Weights 2. Damaged guard 21. Other 13. PART OF BODY OFF CAMPUS 3. Inadequate illumination 1. Head 24. Field trip 4. Inadequate ventilation HAND TOOLS 5. Hazardous procedure 22. Chisel 2. Face EN ROUTE 6. Slippery/uneven surfaces 23. Drill 3. Eye 25. School bus 7. Other 24. File 4. Cheek 26. System car, truck, van 21. PERSONAL FACTOR 25. Hammer 5. Nose 27. Commercial carrier 1. Poor safety attitude 26. Knife 6. Chin 28. Private car, truck, van 2. Failure to follow instructions 27. Needle 7. Ear 29. Leased vehicle 28. Paper cutter 8. Neck 30. Bicycle 29. Hand Saw 9. Torso 31. Motorcycle 30. Scissors 10. Arm 32. Skateboard 31. Screwdriver 11. Hand 33. Skating 32. Wrench 12. Finger 33. Other 13. Leg