Page 1

Yokohama International School

Report of Injury, Illness or Incident Reason for Report:

□Injury □Illness □Incident

Patient Name: _________________________________ Class:_________ Patient Status: □Student □Faculty/Staff □Parents □Other person Age: (circle) 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Adult Sex: (circle) Male / Female

Date: _______________________Time:_____:______AM/PM Type of Injury/Illness: □Allergic reaction □Animal bite/Sting □Bone/joint injury □Burn □Choking □Dental injury □Eye injury □Head injury □Heat/Cold related emergency □Medical Condition ( □Psychiatric Emergency □Wound □Respiratory Emergency □Sprain/Strain □Trip / Slip □Others ( )


Body Part Injured: □Ankle (R/L) □Arm (R/L) □Back □Chest □Ear (R/L) □Elbow (R/L) □Eye (R/L) □Face □Finger □Foot (R/L) □Hand (R/L) □Head □Hip□Knee (R/L) □Leg (R/L) □Mouth/Tooth □Nose □Wrist (R/L) □Other ( )

Description of how incident occurred: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

Location of Incident: ___________________________________________________________________________ __________________________________________________________________________________ ___________________________________________________________________________________

First Aid Treatment Required: Y_____ N______ Type of Treatment provided: ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________

By whom?__________________________ Advised to seek medical treatment? Y_____ N_____ Was hospital care called for or provided? Y _____ N_____ If Yes, Emergency___ Admitted____ How was patient transported: Ambulance_____ Private Vehicle_____ Other_____________ Was the risk of this injury/incident identified in the Risk Management Forms? Y____ N____ If no, please explain ___________________________________________________________________________________ ___________________________________________________________________________________

Full Name and Position of Person Completing Report: _________________________________________ signature:__________________________ *Original to  Student’s  Health  File,  copies  to  Headmaster,  Safety  Director,  Principal  and  Office  

Report of Injury

☆ Please give a detailed written report on the timeline of the event, the accident and actions taken.

☆ Describe any action that has since been taken or perhaps could be taken to prevent a similar accident

☆ Any other comments or observations?

                                                                                                                         *Original  to  Student’s  Health  File,  copies  to  Headmaster,  Safety  Director,  Principal  and  Office  

Report of Injury Form  

Form for Teachers

Read more
Read more
Similar to
Popular now
Just for you