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 Description: Please describe what happened and any immediate actions taken.
*
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: