Glenwood Community School District
Injury Report
Name ___________________________________ M/F DOB____/____/_____
Last First Circle Month Day Year
Grade/Room_________________________ School_______________________
Time of Injury______________________ Date of Injury_______________________
Place Accident Occurred__________________________________________________________
Description of Incident____________________________________________________
______________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Staff Member Present__________________________________________________
Action by Staff:
First Aid_______________________________________________________________
______________________________________________________________________
At_________________________________ By_______________________________________
Injury to_______________________ Assessment of Injury_____________________
______________________________________________________________________
Parent/Guardian Notified at____________________ by________________________
Parent/Guardian Name___________________________________________________
Recommendation for further treatment_______________________________________
Action taken by Parent/Guardian____________________________________________
Student absent from school_____Yes _____No Number of Days_______________
Student hospitalized_____Yes _____No Number of Days_______________
Nurse Signature________________________________________ Date__________
Teacher Signature_______________________________________ Date__________
Principal Signature______________________________________ Date__________
*Adopted: 12/13/10
*Revised: 02/11/13
*Reviewed: 09/18/17
*Reviewed: 9/27/22
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