HYDE PARK CENTRAL SCHOOL DISTRICT

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            Accident Occurred:                    Home School:

• School                                    ¨ Hyde Park Elementary     ¨ Ralph R. Smith Elementary
• Extra Curricular Activities       ¨ Netherwood Elementary     ¨ Violet Avenue Elementary
• Field Trip                               ¨ North Park Elementary     ¨ Haviland Middle School
• Athletics                                                                             ¨ FDR High School
• Intramurals                                                                  
• Clubs

Student Name: _____________________________DOB:_______________Grade:______________

Address: __________________________________________________________________________

Parent/Guardian: ___________________________________________Phone:_________________

Date of Accident: __________________________Day:______________Time:___________AM/PM

Location Where Accident Occurred: ___________________________________________________

Body Part: ________________________________________________________________________

Injury Type (Please be specific):_______________________________________________________

Detailed Accident Description:

       School Authority in Charge of Activity: ________________________________________________

       Did Child Attend School That Day:¨ YES¨ NO

       First Aid Treatment Given By: _______________________________________________________

       Parent/Guardian Notified: ___________________________Time:_______ AM/PM Date: _______

                                                              (Name)

¨ Student Returned to Class          ¨ Sent Home       ¨ To Hospital_______________________                                

                                                                                                             (Name of Hospital)                                                                                                        

¨ To Doctor: _____________________________          ¨ Other: ___________________________                                                                              (Name of Doctor)                                                                                             (Please be Specific)

Method of Transportation: ___________________ By Whom: ______________________________

_______________________________________  ___________________________________________Report Prepared by                    Date                  Principal’s Signature                 Date

Within 24 hours, please fax this form to:                         Fax#:                                                                                                            

• Assistant Superintendent of PPS                   229-4017
• Health Office at Haviland MS                       229-2475
• Health Office of Student’s Home School                                                                                                                                                             

Updated 03/05 PPS