Western Dubuque County Community School District
Student Accident Report
8/22/2019
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RECOMMENDED STANDARD STUDENT ACCIDENT REPORT

Western Dubuque Co. Comm. School District, Farley, Iowa

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GENERAL

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Student First Name
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Student Last Name

Address (Include street address, PO Box, City, State, Zip)
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Parent/Guardian Name
()- Ext.
Home Phone
*
School Name
*
Sex

Age
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Grade/Special Program
*
Date Accident Occurred (mm/dd/yyyy)
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Exact Time Accident Occurred
*
Day of Week Accident Occurred
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INJURY

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Nature of Injury
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Part of Body Injured
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Degree of Injury (Select one)
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Days Lost From School (Enter in half-day increments)
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Days Lost From Activities Other Than School (Enter in half-day increments)
Total Days Lost:
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Cause of Injury

ACCIDENT

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Accident Jurisdiction (select one)
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Location of Accident (be specific)
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Activity of Person (be specific)
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Supervision?

If yes, give name and title of supervisor
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Witnesses

Unsafe Mechanical/Physical Condition

Unsafe Personal Factor

Corrective Action Taken or Recommended

School Property Damage Estimate ($)

Non-School Property Damage Estimate ($)
Total Property Damage Estimate:
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Description (Give a word picture of the accident, explaining who, what, where, when, why and how)

SIGNATURE

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Report Prepared by (signature)
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Report Prepared by (title)
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Date of Report (mm/dd/yyyy)

Nurse's signature

Report Prepared by (title)

Date of Report (mm/dd/yyyy)
Routing Instructions
Please route this form as indicated below. You need only route to the next level and the other levels are routed automatically.
1. School Nurse
2. Building Principal/Department Head
3. Business Manager
Complete the information below to route your form. * Indicates Required Fields
Your Name:
* Your E-mail: *
Confirm E-mail: *
Send to Approver:  
No approver has been assigned to this form, please contact your District Forms Manager.