Student's Name *

Location Incident Occurred

Date

Time of Incident

Type of Incident

• Illness
• Injury
• Behavior

Type of Illness

• Fever
• Eye Discharge
• Rash
• Cough
• Diarrhea
• Lice
• Vomiting
• Other

May Return In

• 24 Hours
• 48 Hours
• 72 Hours
• Doctors Note Required

type of Injury

• Bite
• Bruise/Bump
• Cut/Scape
• Splinter
• Allergy
• Choking
• Eye Injury
• Nose Injury
• Head Injury

Cause of Injury

• Fall/Trip
• Bumbed into Object
• Another
• Running
• Climbing
• Other

* If "Other", fill in

First Aid Given

• Wash/Cleaned
• Ice Pack
• Band Aid

Parents Notified

• Verbal
• Called
• Messaged

Comments

Parent's Name *

Teacher's Name *

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