Twin Valley Community Local School District Student Injury Report
Guidelines The Ohio Department of Health (ODH) provides the following Student Injury Report and Guidelines as an example for district to use in tracking the occurrence of school-related injuries. ODH suggests completing the form when an injury leads to any of the following:
1. The student misses ½ day or more of school. 2. The student seeks medical attention (health care provider office, urgent care center, emergency department). 3. EMS 9-1-1 is called.
Schools are encouraged to review and use the information collected on the injury report to influence local policies and procedures as needed to remedy hazards.
Instructions
Student, parent and school information: self explanatory.
Check the box to indicate the location and time the incident occurred.
Check the box to indicate if equipment was involved; describe involved equipment. Indicate what type of surface was present where the injury occurred.
Using the grid, check the body area(s) where the student was injured and indicate what type of injury occurred. Include all body areas and injuries that apply.
Check the appropriate box(es) for factors that may have contributed to the student’s injury.
Provide a detailed description of the incident. Indicate any witnesses to the event and any staff members who were present. Attach another sheet if more room is needed.
Incident Response: include all areas that apply.
Provided any further comments about this incident, including any suggestions for what might prevent this type of incident in the future.
Sign the completed form.
Route the form to the school nurse and the principal for review/signature.
Original form and copies should be filed according to district policy.
TVS-00-0048 5/4/2018 Twin Valley Community Local School District Student Injury Report
Student Information Incident Name: Date: Date of Grade Incident Birth: : Male Female Time:
Parent/Guardian Information
Name(s): Work Phone: ( ) Home Address: Phone: ( )
City: State: Zip: Cell Phone: ( )
School Information
School: Phone: ( )
Location of Incident check appropriate box Athletic Field Cafeteria Classroom # Gymnasium Stairway Parking Lot Hallway Locker Room Bus # Restroom Shop/Lab Playground Other (explain):
Time of Incident check appropriate box Recess Lunch P.E. Class In class (not P.E.) Athletic Team Competition Class Change Field Trip Before School After School Unknown Intramural Competition Other (explain):
Equipment check appropriate box No Equipment Involved Yes, Equipment Involved If yes describe:
Surface check all that apply Asphalt Carpet Concrete Dirt Gravel Sand Synthetic Surface Gymnasium Floor Ice/Snow Lawn/Grass Mat(s) Tile Water Wood Chips/Mulch Other (explain):
Type of Injury check all that apply t s h a s e l t p m i n p r i o b s n e i r a e e i l r r m t e o e n t H e e d L w r a d n k d e l h n A s i r R e / e / t g b l m r s T i i e o a a n c o / w g i k s r a / o r T y r e o h t e u o o h e i e n a a o a / b r t n n n a e h s r E l g o i d E J L T l v t k F e u C N B e H l p K H l W o G n A h b E F o c o i h e o p G F e S o A F P C C U M T N
Abrasion/Scrape Bite Bump/Swelling Bruise Burn/Scald Cut/Laceration Dislocation Fracture Pain/tenderness Puncture Sprain Other
TVS-00-0048 5/4/2018 Twin Valley Community Local School District Student Injury Report
Contributing Factors check all that apply Animal Bite Compression/Pinch Foreign body/object Physical Altercation Struck by Object Collision w/ Object Drug, Alcohol, other Hit w/ thrown object Struck by auto, bike, etc. Tripped/Slipped Collision w/ Person Fall Overextension/twisted Contact w/ hot or Toxic substance Weapon (specify): Other (explain):
Description of the Incident
Witness to the Incident
Staff Involved check all that apply Assistant Staff Bus Driver Cafeteria Staff Custodian Nurse Principal Secretary Teacher Other (explain):
Incident Response check all that apply First Aid Time: By Whom: Called 911 Time: By Whom: Parent/Guardian Notified Time: By Whom: Unable to Contact Parent/Guardian Time: By Whom: Parents Deemed No Medical Action Necessary Returned to Class Sent/Taken Home # Days Missed: Taken to Doctor/Clinic/Hospital/Urgent Care Diagnosis: # Days Missed: Hospitalized Diagnosis: # Days Missed: Restricted School Activity Explain: How Long? # Days Missed: Other (explain):
Describe Care Provided to the Student
Additional Comments
Signatures
Staff Completing Form: Date/ Time:
Nurse: Date/ Time:
Principal: Date/ Time:
TVS-00-0048 5/4/2018