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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

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