Charlotte Public School Incident Reporting Form

Charlotte Public School Incident Reporting Form

Report of Incident - Visitor

School building where incident occurred ______Date ______

Injured person______Address______

Street City State Zip

Parent ______Address ______Phone ______

Day Evening

General Information

Describe exactly what happened. ______

______

______

______

Medical Information

Describe the injured party’s condition and any first aid. Was first aid given? ______Blood-borne exposures? ______

______

______

Further medical attention? ______If so, where and by whom: ______

Was parent / guardian / emergency contact notified? ______If so, when? ______

Who was called and what was the outcome? ______

With whom did the injured party leave the site? ______

Witnesses (indicate staff [s], participant [p], or volunteer [v])

S P V Name Age Phone Address City State Zip

______

______

______

Incident Management

Signature of injured person (18 and over) Date

Employee Filing Report ______Position Date ___

Parent Signature Date

Administrator Reviewing Report ______Position Date

Follow-up required by Supervisor or Building Principal within 48 hours of the incident

Follow up date ______And by whom? ______

Detail status.

Please check one and only one box in each of the following sections

Specific Location of Incident

__ Aquatic: Main Pool__ Aquatic: Exercise Pool__ Meeting Room __ Locker Room

__ Lobby / halls / stairs__ Athletic Field __ Parking lot / Garage __ Cabin

__ Play structure or area: interior __ Running track__ Gymnasium__ Restroom

__ Playground (i.e., with equipment) __ Childcare site__ Classroom__ Cafeteria

__ Media Center__ Bus__ Other ______

Program

(indicate name)______

__ Aquatics __ Childcare__ Adult Fitness__ Special Events

__ Field Trips__ 7th grade Camp__ Non-sport activities __ Sports: Informal

__ Sports: Adult__ Sports: Youth__ Outdoor Education __ Senior program / activity

__ Community Ed class__ School Session__ Athletic Event/Game

__ Ski Club__ Other ______

General Activity

__ Aquatics: exercise class __ Free / unstructured play __ Skiing / snowboarding__ Volleyball

__ Aquatics: family / open swim __ Games / structured play __ Soccer__ Football

__ Aquatics: lap swim __ Dance / Gymnastics __ Baseball / Softball / T-ball__ Basketball

__ Aquatics: lessons __ Dressing / Undressing __ Theft / robbery__ Track / Cross Country

__ Aquatics: team (incl. practice)__ Transportation__ Exercise: Free weights__ Exercise: Run / walk

__ Band/Choir – Practice/Event__ Classroom Instruction__ Exercise: Strength equip

__ Playground equipment __ Other ______

Specific Action

__ Aggressive behavior of / by __ Exertion __ Inappropriate touch __ Struck by / against

__ Caught in, by, or between __ Fall (from, onto, into, or against)__ Inhale / ingest __ Contact with / exposure to

__ Verbal attack / taunt / teasing__ Horseplay__ Pushed/pulled/bumped__ Inappropriate Language

__ Handle / use / touch__ Participation / playing __ Other ______

Source of Injury

__ Aquatics: deck __ Blood / body fluids __ Floor / Ground __Person (another)

__ Aquatics: equipment __ Door__ Furniture__Self

__ Aquatics: sides / bottom__ Environment: sun, heat, etc. __ Insect / animal __Wall / vertical surface

__ Aquatics: water, body of__ Equipment: Exercise __ Locker / cabinet __ Object (ball / bat / toy / etc.)

Equipment: Playground__ Other ______

If the equipment or property was defective, who was notified for repair or follow up:

Person Notified: ______By whom: ______date _ __

What action was taken / date of repair completed:

Describe: ______

Date: ____ _

Apparent Injury

__ Abrasion / scratch __ Bruise / contusion __ Fear / intimidation __ Seizure / dysfunction

__ Aquatic distress __ Burn / blister __ Fracture / break__ Sprain / strain

__ Bite / sting __Cramp__ Irritation / reaction __ Vomiting

__ Bloody / hemorrhage__ Cut / puncture __ Jam__ No visible / apparent injury

__ Breathing shortened / impaired __ Dislocation __ Pain / soreness __ Dizziness / Unconscious __ Pinch/Crush __Other ______

Body Part

please check if applicable: O right O left O upper O lower

__ Arm __ Leg __ Shoulder __ Back __ Face __ Head __ Mouth / lips / teeth

__ Hand / finger__ Foot / toe __ Chest __ Buttocks __ Ear __ Neck __ Mind / psyche

__ Wrist __ Ankle __ Stomach __ Hip__ Eye__ Heart __ None / not applicable

__ Elbow__ Knee __ Side __ Groin __ Nose__ Lungs __ Other ______

Forward this completed form to the Executive Director of Business, Operations & HR, within 48 hours of this incident / injury.

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