Accident/Incident/Illness Report Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Pupil's Name *Form completed by *Was this an incident you witnessed? *YesNo (another adult did)A pupil witnessed the incidentNobody witnessed the incidentThere was no incident - the pupil told me they felt unwellWho witnessed this incident? *FirstLastDate / Time (to the nearest 15 minutes) *DateTimeClass *DelphinusPegasusOrionCygnusPhoenixDoradoTESTLocation and details of accident/incident/illness *Head injuryRednessAsthmaBump/bruiseCut/GrazeHeadacheHigh temperatureVomiting/nauseaSprains/twistsNosebleedStomach pains/upset stomachFacial injury/discomfortEye injuryTLC appliedRashSigns and Symptoms of head injury *Head injury - Visible bumpHead injury - Visible bruiseHead injury - BleedingHead injury - RednessPupil said they felt sickPupil was sickPupil said they felt dizzyPupil was concussedOther (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 painAsthma - shortness of breathAsthma - difficulty breathingAsthma - wheezing – whistling noise when breathingAsthma - coughingOther (please specify)Please complete the paper form if the child needs to use an inhaler.Signs and Symptoms of bump/bruise *Bump/Bruise - Fell overBump/Bruise - Bumped into another pupilBump/Bruise - Pupil couldn't move the affected areaBump/Bruise - SwellingBump/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/grazeCut/Graze - lacerationSpecify where on the body was the cut/grazeWhere on the body was the cut/graze *Signs and Symptoms of headache *Headache - Pain that starts slowlyHeadache - Head hurting on both sidesHeadache - Pain that is dullHeadache - Pain that feels like a band around the headHeadache - Pain in the back part of the head or neckHeadache - Pain mild to moderate, but not severeHeadache - Pain is severeOther CommentsAdditional comments (Headache) *Signs and Symptoms of a high temperature *High temperature - Pupil told us they were feeling unwellHigh temperature - Pupil told us they were feeling hotHigh temperature - Pupil told us they were feeling coldHigh temperature - Pupil looked paleHigh temperature - Pupil appeared sweaty and flushedHigh temperature - Pupil was shiveringSpecify the temperature of the pupilSigns and Symptoms of pupil feeling nauseous or has been sick *Vomiting/Nausea - Pupil informed of feeling sick but wasn't sickVomiting/Nausea - Pupil informed they had been sickVomiting/Nausea - Pupil informed they have loose stoolsVomiting/Nausea - Pupil also bumped headVomiting/Nausea - Pupil feels stomach crampsOtherAdditional comments (vomiting/nausea) *Signs and Symptoms of sprain/twist *Sprain/Twist - pain, either at the time of injury or laterSprain/Twist - tenderness in the soft tissue, usually close to the boneSprain/Twist - swelling or bruisingSprain/Twist - weakness or pain when using or moving the injured areaWhat part of the body has been affected? How did it happen? *Signs and Symptoms of nosebleed *Nosebleed - Pupil bumped their nose causing it to bleedNosebleed - Bleeding from one nostrilNosebleed - Bleeding from both nostrilsDescribe the severity of the nosebleed *Signs and Symptoms of upset stomach/stomach pains *Stomach pains - Eaten beforehandStomach pains - Pupil cramped up in painStomach pains - Pupil attempted to use the toiletOtherOther (stomach pains) *Signs and Symptoms of facial injury/discomfort *Facial injury - To the eyeFacial injury - To the mouthFacial injury - To the lipFacial injury - ToothacheFacial injury - Missing toothFacial discomfort - EaracheFacial discomfort - Nasal painFacial discomfort - Sore throatOtherOther (facial injury/discomfort) *Describe the use of TLC *How was the pupil comforted?What kind of first aid was applied?Pupil declined first aidCold compress (wet paper towel)Ice packPlasterTissueAsthma pump (with recommended dosage)Washed the areaNot neededOtherDescribe the first aid applied *How many doses of the asthma pump were given? *Location of incidentMain playgroundReception playgroundNursery playgroundShelterIn a classroomOtherWhere 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?Additional commentsIn 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).Do you need to inform the school office? *YesNoTap 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.Submit
