<p>Twin Valley Community Local School District Student Injury Report</p><p>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:</p><p>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.</p><p>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. </p><p>Instructions</p><p> Student, parent and school information: self explanatory.</p><p> Check the box to indicate the location and time the incident occurred.</p><p> Check the box to indicate if equipment was involved; describe involved equipment. Indicate what type of surface was present where the injury occurred.</p><p> 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.</p><p> Check the appropriate box(es) for factors that may have contributed to the student’s injury.</p><p> 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.</p><p> Incident Response: include all areas that apply.</p><p> Provided any further comments about this incident, including any suggestions for what might prevent this type of incident in the future.</p><p> Sign the completed form.</p><p> Route the form to the school nurse and the principal for review/signature.</p><p> Original form and copies should be filed according to district policy.</p><p>TVS-00-0048 5/4/2018 Twin Valley Community Local School District Student Injury Report</p><p>Student Information Incident Name: Date: Date of Grade Incident Birth: : Male Female Time: </p><p>Parent/Guardian Information</p><p>Name(s): Work Phone: ( ) Home Address: Phone: ( ) </p><p>City: State: Zip: Cell Phone: ( ) </p><p>School Information</p><p>School: Phone: ( ) </p><p>Location of Incident check appropriate box Athletic Field Cafeteria Classroom # Gymnasium Stairway Parking Lot Hallway Locker Room Bus # Restroom Shop/Lab Playground Other (explain): </p><p>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): </p><p>Equipment check appropriate box No Equipment Involved Yes, Equipment Involved If yes describe: </p><p>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): </p><p>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</p><p>Abrasion/Scrape Bite Bump/Swelling Bruise Burn/Scald Cut/Laceration Dislocation Fracture Pain/tenderness Puncture Sprain Other </p><p>TVS-00-0048 5/4/2018 Twin Valley Community Local School District Student Injury Report</p><p>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): </p><p>Description of the Incident </p><p>Witness to the Incident </p><p>Staff Involved check all that apply Assistant Staff Bus Driver Cafeteria Staff Custodian Nurse Principal Secretary Teacher Other (explain): </p><p>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): </p><p>Describe Care Provided to the Student</p><p>Additional Comments</p><p>Signatures</p><p>Staff Completing Form: Date/ Time: </p><p>Nurse: Date/ Time: </p><p>Principal: Date/ Time: </p><p>TVS-00-0048 5/4/2018 </p>