JCC Injury Report Form

JCC Injury Report Form

Student/Employee Name DOB Grade

Date and Time of Injury Body Part Injured

Location (Building/Room) Where Injury Occurred

Was the Injury Witnessed? Yes No     By Whom?

Explain Details of Injury (how injury occurred and anyone involved)

What First Aid Was Provided? Press Ctl key to select more than one option.

Other First Aid

Was Parent/Guardian Notified? Yes No     Who?

Was EMS Called? Yes No   Was the Nursing Staff Notified? Yes No

The Student/Employee Went:   Home with or other

Reporting Person Date/Time

This section to be completed by nursing staff.

Reviewed by   Date/Time

Follow up needed? Yes No


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