Fill and Sign the University of Toledo Body Donation Program Form

WORK PRODUCT PRIVILEGE This report is to be completed by school district employees. This form is a confidential, internal, document; its contents are not to be shared or copied for any persons who are not school district employees and/or their legal representatives. Redlands Unified School District Student Accident Report CONFIDENTIAL-ATTORNEY/CLIENT 20 W. Lugonia Avenue Redlands CA 92374 (909) 307-5300 (909) 307-5344 (fax) IN CASE OF SERIOUS INJURIES, A TELEPHONE REPORT IS TO BE MADE IMMEDIATELY. The employee either witnessing the accident or supervising at the time must complete and submit this form by the end of the day. Date: Name of School: Name of Injured Student (Last, First, M.I.): Is injured student a minor? yes Name of Parent/Legal Guardian: Age: Grade: no Telephone Number of Parent/Legal Guardian: Address of Injured Student (Number, Street, Apartment Number, City, State, Zip Code): Where did accident occur? Date: Time: am pm yes no Describe how accident occurred (state facts only) Was student violating school rules at the time of the accident? Name of individual in charge at the time (Last, First): Title (teacher, volunteer, etc): Was he/she present? yes Names of Witness(es) Address no Status (student/volunteer) Nature of injury (please check): Parts of body involved (please check): Head Finger Arm Abdomen Abrasion Fracture Insect bite Chipped tooth Contusion Cut Sprain Human bite Neck Eye Leg Hand Bruise Concussion Dislocation Internal (area): Back Chest Face Foot Other (explain): Other (explain): First Aid procedures used: Name of person administering First Aid: Disposition of injured student after accident or class: Name of individual notified: If injured student left school, to whom was he/she released: Name and attitude of individuals contacting school: Relationship to student: Remarks: Name of individual completing report: Address of individual completing report (school site): Status (teacher, clerk, etc): Telephone No. Was individual a witness? yes Signature of Principal/Supervisor: no Date signed: Original - District Office/Risk Management Bus Svc/Risk Mgmt Revised 10/2010 Print Form