Student Injury Report
Bemidji Area Schools
Student Information
Student's Full Name
*
First Name
Middle Initial
Last Name
Suffix
Grade
*
Pre-K
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
Gender
*
Male
Female
N/A
School / Location of Injury
*
Bemidji High School
Bemidji Middle School
Gene Dillon Elementary
Horace May Elementary
J.W. Smith Elementary
Lakeside
Lincoln Elementary
Northern Elementary
Solway Elementary
Jack & Jill
Paul Bunyan Elementary
Kids & Company (select building location as well)
School Bus
Injury Details
Date of Injury
*
-
Month
-
Day
Year
Time of Injury
*
AM
PM
AM/PM Option
Days Absent (time if less than a full day)
*
Body Part Injured
*
Type of First Aid Applied
*
Type of Injury Suspected
*
Surface Cut/Scratch
Laceration/Abrasion
Bruise/Contusion
Sprain/Strain
Fracture
Dislocation
Burn
Concussion
Other
Accident Location
*
Classroom
P.E. Classroom
Gym
Stairs
Hallway
Playground
Bus
Other
Please list any Witness(es) along with their contact information:
Parent Notified
*
Yes
No
Action Taken
*
Returned to class
Time spent in health office
Parent brought home
Parent brought to doctor
Parent brought to ER
Transferred to hospital
Called 911
Other
Detailed Student Account of How Injury Occurred
*
Other Notes / Follow Up
Exposure
Did the injury result from an exposure? An exposure is defined as blood contact with mucous membranes, non-intact skin, or piercing the skin or mucous membrane by needle stick, cut or bite.
*
Yes
No
Additional information regarding the exposure incident:
If applicable, please take a photo of the item that was involved in the injury.
Equipment
Complete this section if the injury resulted from the use of school and/or playground equipment.
Was playground equipment involved in the injury?
*
Yes
No (if "No", skip to the approvals section)
If yes, was the equipment used appropriately?
Yes
No
Unknown
Other
Type of Equipment
If applicable, please take a photo of the playground equipment involved in the injury.
Attachments
File Upload (if applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Approvals
Report Completed By
*
First Name
Last Name
Submitter's Email
*
Signature
*
Date Submitted
*
-
Month
-
Day
Year
Date
Email
example@example.com
Follow Up Notes (Added after the report was submitted)
Submit
Should be Empty: