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    Employer's Report of Work Injury and Illness
Athletic & Student Accident Notification of Injury
Part I: School Report
Fields marked in BOLD are required
Date of Accident
Time:
School System:
Name of School Child Attends:
Phone:
First Name:
Middle Initial:
Last Name:
Social Security Number:
Grade:
Birthdate:
Gender:
Part of Body Injured:
  Right
Left
Describe Nature of Injury and How Injury Occurred:
Name of Activity/Class:
Person Completing This Form:
Title:
Date Signed:

Parent/Guardian Information
All fields are required in this section.
Name of Parent/Guardian:
Address:
City:
State:

Zip:
Daytime Telephone #:
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