Star Academy

Accident Injury Medical Report (Non-Students)

Accident / Injury / Medical Report (Non-Students)
CHECK ONE
- ACCIDENT/INJURY
- MEDICAL
Injured/Ill Person's Name*
Injured/Ill Person's Role*
- Staff
- Support Workers
- Visitor
Reason for visit*
Date
Date Format: MM slash DD slash YYYY
Time
Witnesses
Location
Reporting Staff
Description of Injury/Illness
Describe how the injury occurred. If illness describe.
What body part(s) were injured/affected? Describe.
Was this a head injury?
- YES
- NO
FOLLOW UP
Describe any First Aid given, and include the staff member who provided the aid.
Treatment Duration Staff Member Initials
Following treatment, the injured/ill:
- returned to regular duties
- rested in office
- left by themselves
- family member called
- ambulance called
Emergency
Was this an emergency?
- YES
- NO
IF YES, who called 911?
Was injured/ill person taken to Hospital?
- YES
- NO
IF YES, how was the injured/ill person transported?
who accompanied the injured/ill person?
Upload files/documents
Drop files here or
Notification Log
Include a log of contact with injured/ill following the incident.
Provide details of follow-up treatment
Date Practitioner Location Assessment
Witness Signatures
Reporting Staff Signature
All reports will be sent to Heather and Julie. Do you also want to send this form submission to anyone else?*
- Yes
- No
Recipient*
Do you want to send this form submission to anyone else?*
- Yes
- No
Recipient*
Do you want to send this form submission to anyone else?*
- Yes
- No
Recipient*

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Treatment	Duration	Staff Member	Initials

Date	Practitioner	Location	Assessment