Fillable 1. Section to be completed by School Administrator, (Wake County Public School System)

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1. Section to be completed by School Administrator, (Wake County Public School System)

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The 1. Section to be completed by School Administrator, (Wake County Public School System) form is 2 pages long and contains:

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  • 17 check-boxes
  • 25 other fields

Country of origin: US
File type: PDF

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Page 1 of 2
1. Section to be completed by School Administrator, Supervising Teacher or other employee.
Injured Person
Last Name:
First Name:
Date of Injury:
Time:
School Name:
Grade:
Age:
Before/After Program:
Room or location where injury occurred:
Parts of body injured:
Nature of injury: ☐ Laceration ☐ Fracture ☐ Sprain/Strain ☐ Burn ☐ Amputation
☐ Electrical Shock ☐ Puncture ☐ Bruise/Contusion ☐ Dislocation
☐ Head Injury ☐ Other / Describe Head Injury or Other:
Description of accident (how, what, why?):
Specify tool or equipment involved:
Corrective Action to prevent the same type of accident:
Witnesses or participants:
Form completed by:
Date:
WCPSS Employee Signature:__________________________________________________________
Page 2 of 2
2. Section to be completed by person giving treatment or assistance.
Immediate action taken:
☐ First aid treatment (ice, washed wound, kept immobile, observed, stopped bleeding, applied splint,
applied dressing)
☐ Released to parent ☐ Called 911 ☐ Parent or self took to physician/ER
Name of Physician:
Sent to Hospital or Urgent Care:
☐ Yes ☐ No
Name of Hospital or Urgent Care:
Other:
Individual Notified (Parent / Guardian / Other)
Name:
Phone #:
Time and method of notification or attempt to
notify:
Remarks:
Form completed by:
Date:
Email one (1) copy of this report to Risk Management: rm-accident-reports@wcpss.net
Retain one (1) copy for your file.
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1. Section to be completed by School Administrator, (Wake County Public School System)

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Completed 16 November 2021

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