Accident/Illness Form

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Name *

Form completed by *

Are you reporting a pupil or an adult? *

Pupil
Adult

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What are you reporting?

Accident
Illness
Incident (injury related)
Near Miss

Was this an incident you witnessed? *

Yes
No (another adult did)
A pupil witnessed the incident
Nobody witnessed the incident

Was it any of the following near misses (or similar) (use 'Other' to specify) *

A child tripped on an uneven paving slab/tree root but caught themselves before falling.
A chair tipped backwards when a pupil leaned but didn’t result in a fall.
A classroom cupboard door swung open unexpectedly and narrowly missed a child.
A heavy book/resource box slipped from a shelf but was caught before landing on anyone.
A pupil ran into a door just as another child was opening it but no contact was made.
A PE bench wobbled as pupils climbed on but didn’t collapse.
I noticed a hot drinks flask left within reach of pupils but removed it before harm.
A puddle/spillage in the hall caused a slip but the child regained balance without falling.
An electrical cable was trailing across the floor and someone nearly tripped.
Other

Please specify the near miss *

Who witnessed this incident? *

First

Last

Date / Time (to the nearest 15 minutes) *

Date

Time

Class *

Location and details of accident/illness *

Head injury
Redness
Asthma
Bump/bruise
Cut/Graze
Headache
High temperature
Vomiting/nausea
Sprains/twists
Nosebleed
Stomach pains/upset stomach
Facial injury/discomfort
Eye injury
TLC applied
Rash
Fall

Signs and Symptoms of head injury *

Head injury - Visible bump
Head injury - Visible bruise
Head injury - Bleeding
Head injury - Redness
Pupil said they felt sick
Pupil was sick
Pupil said they felt dizzy
Pupil was concussed
No visible injury
Other (please specify)

Please specify any other signs/symptoms of the head injury *

Were there any of the following signs? Did the pupil show a bump, bruise or bleeding? Did they feel sick or dizzy? Did they experience concussion? Describe which part of the head the injury happened on.

Signs and Symptoms of asthma *

Asthma - chest tightness or pain
Asthma - shortness of breath
Asthma - difficulty breathing
Asthma - wheezing – whistling noise when breathing
Asthma - coughing
Other (please specify)

Please complete the paper form if the child needs to use an inhaler.

Signs and Symptoms of bump/bruise *

Bump/Bruise - Fell over
Bump/Bruise - Bumped into another pupil
Bump/Bruise - Pupil couldn't move the affected area
Bump/Bruise - Swelling
Bump/Bruise - Intense pain (pupil distressed)
Other (please specify)

Please specify any other signs/symptoms of the bump/bruise *

Signs and Symptoms of the cut/graze *

Cut/Graze - superficial cut/graze
Cut/Graze - laceration
Specify where on the body was the cut/graze

Where on the body was the cut/graze *

Signs and Symptoms of headache *

Headache - Pain that starts slowly
Headache - Head hurting on both sides
Headache - Pain that is dull
Headache - Pain that feels like a band around the head
Headache - Pain in the back part of the head or neck
Headache - Pain mild to moderate, but not severe
Headache - Pain is severe
Other Comments

Additional comments (Headache) *

Signs and Symptoms of a high temperature *

High temperature - Pupil told us they were feeling unwell
High temperature - Pupil told us they were feeling hot
High temperature - Pupil told us they were feeling cold
High temperature - Pupil looked pale
High temperature - Pupil appeared sweaty and flushed
High temperature - Pupil was shivering
Specify the temperature of the pupil

Signs and Symptoms of pupil feeling nauseous or has been sick *

Vomiting/Nausea - Pupil informed of feeling sick but wasn't sick
Vomiting/Nausea - Pupil informed they had been sick
Vomiting/Nausea - Pupil informed they have loose stools
Vomiting/Nausea - Pupil also bumped head
Vomiting/Nausea - Pupil feels stomach cramps
Other

Additional comments (vomiting/nausea) *

Signs and Symptoms of sprain/twist *

Sprain/Twist - pain, either at the time of injury or later
Sprain/Twist - tenderness in the soft tissue, usually close to the bone
Sprain/Twist - swelling or bruising
Sprain/Twist - weakness or pain when using or moving the injured area

What part of the body has been affected? How did it happen? *

Signs and Symptoms of nosebleed *

Nosebleed - Pupil bumped their nose causing it to bleed
Nosebleed - Bleeding from one nostril
Nosebleed - Bleeding from both nostrils

Describe the severity of the nosebleed *

Signs and Symptoms of upset stomach/stomach pains *

Stomach pains - Eaten beforehand
Stomach pains - Pupil cramped up in pain
Stomach pains - Pupil attempted to use the toilet
Other

Other (stomach pains) *

Signs and Symptoms of facial injury/discomfort *

Facial injury - To the eye
Facial injury - To the mouth
Facial injury - To the lip
Facial injury - Toothache
Facial injury - Missing tooth
Facial discomfort - Earache
Facial discomfort - Nasal pain
Facial discomfort - Sore throat
Other

Other (facial injury/discomfort) *

Describe the use of TLC *

How was the pupil comforted?

What kind of first aid was applied?

Pupil declined first aid
Cold compress (wet paper towel)
Ice pack
Plaster
Tissue
Asthma pump (with recommended dosage)
Washed the area
Not needed
Other

Describe the first aid applied *

How many doses of the asthma pump were given? *

Location of incident

Main playground
Reception playground
Nursery playground
Shelter
In a classroom
Other

Where in or out of the school did this occur? e.g. the trim track in the main playground, or in Phoenix Class by the reading area.

Where?

Describe how you supported the person or what happened

This is essential to complete, however if you didn't need to support, please state who did. Also this replaces the additional information box which said: In this section, if an injury occurred, be specific with which part of the body was affected (e.g. right hand index finger, or bruise to the left cheek).

Upload any relevant evidence should you need to

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Do you need to inform the school office? *

Tap Yes if the pupil suffered a head injury, has a high temperature, has had an asthma attack, a major bump, bruise, cut or graze, has vomited, has compromised movement as a result of a sprain or twist, has a loose or missing tooth as a result of impact, or if they have had diarrhoea. If you know the pupils' usual class teacher is not with them and will therefore not receive the email notification, tap yes so the office can inform their cover teacher. If you are not sure whether to inform the office, tap yes.

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