EmailMeForm
STUDENT ACCIDENT/INJURY REPORT
__________________________________________________________________________
If a student is injured while participating either in a school sport or activity, an accident/injury report must be completed by the coach or teacher present at the time of injury.
If a parent of an injured student wishes to file a claim with our student accident insurance, a claim form can be requested from the Business Office. This form must be completed by the parent providing details of the details of the accident and treatment of injury. After completion, the form must be returned to the Business Office for an authorized signature and submission to the student accident insurance company. This claim must be filed within 90 days of the date the first medical care was received.
Please note: Northlake’s Student Accident Insurance is secondary. If the parents have other insurance, they must file with their primary insurance first.
Injured student's name
*
First
Last
Student School
*
Please select
Early Learning Center
Elementary School
Secondary School
Student's grade
*
Name of student's parent/guardian
*
Parent/Guardian email address
*
Has the student's parent or guardian been contacted?
*
Yes
No
Date & Time of injury
*
MM
/
DD
/
YYYY
HH
:
MM
AM
PM
AM/PM
Type of activity/sport
*
Recess/Lunch/Afterschool
Athletics
Retreat/Field Trip
Other
If athletics, designate
P.E. Class
Practice
Game
Other
Where and how did accident/injury occur?
*
Part of body injured:
Head (Ear, Eye, Face, Head, Neck, Scalp)
Trunk (Abdomen, Back, Chest, Groin, Shoulder)
Extremities (Ankle, Elbow, Finger, Foot, Hand, Hip, Knee, Arm, Leg)
[Choose as many as necessary]
Name specific body part and left or right (if applicable).
*
Condition of student at time of report (example: student back to playground and happy)
*
Under whose supervision?
*
Was he/she a witness?
*
Yes
No
Was school nurse notified?
*
Yes
No
Report submitted by (your name)
*
First
Last
