ACCIDENT REPORT FORM

IF IN DOUBT, CALL 911 IMMEDIATELY.

ALWAYS ADVISE INJURED PERSON TO SEEK QUALIFIED MEDICAL ADVICE.

First Name of the Injured Person *

Last Name of the Injured Person *

Phone Number *

Email Address *

Date of Injury *

Time of Injury *

Brief description of Injury *

Details of how injury happened *

Attending Instructor

List all students attending that class or witness

How was injury treated by staff?

If injured person was l ess than 18 years of age – was the parent/guardian notified?

Yes

To whom was the injured person released?

Did you recommend medical treatment?

Have all witnesses describe what they saw

Signature *