Flow Forms

Your name

required

Your email address

required

District Name

required

Laurel School District 7-70

Other

Option added

School Name - Out of District

required

Principal's Name

required

School Phone

required

Date of Accident

required

Time of Accident required

Supervising Employee Name

required

Claimant's First Name

required

Claimant's Middle Initial

Claimant's Last Name

required

Claimant's Address - City

Claimant's Address - State

Claimant's Address - Zip Code

Claimant's Social Security Number

Home Phone Number

Claimant's Age

Claimant's Date of Birth

Claimant's Sex

required

Male

Female

Option added

Claimant's Grade

required

Parent's Name (if student)

Parent's Work Phone Number

Nature of Injury

required

Bite

Bruise

Burn

Concussion

Cut/Puncture

Dislocation

Fracture

Head Injury

Scratch

Sprain/Strain

Other

Option added

Place of Accident

required

Athletic Field

Bathroom

Cafeteria

Classroom

Gymnasium

Hallway

Parking Lot

Playground

Sidewalk

Stairs

Other

Option added

Body Part Injured

required

Ankle

Arm

Back

Eye

Face

Finger

Foot

Hand

Knee

Leg

Neck

Nose

Shoulder

Teeth

Wrist

Other

Option added

Describe accident and injury in detail (attach additional description as necessary)

required

Additional Description (optional)

Were efforts made to contact the parent/guardian about the accident?

required

Yes

No

Option added

Was first aid administered?

required

Yes

No

Option added

Who administered first aid?

Optional

Where was the student sent?

required

Home

To Physician

To Hospital

Staying at School

Option added

Is student covered by Student Accident Insurance?

Yes

No

Option added

If yes to the question above, please list Company Name, Address and Phone Number

Name and address of doctor or hospital

Copy of medical bills

Witnesses

Name	Address	Phone

Name

Address

Phone

row changed

please fill in the missing information

Signature of Person Completing the Report required

Accident Report

If medical or hospital treatment was required, please complete the following information.