Employee and Retiree Service Center MONTGOMERY COUNTY PUBLIC SCHOOLS Rockville, Maryland 20855

StuDent AcciDent Report

INSTRUCTIONS: To be completed by school personnel when reporting any accident involving an MCPS student and submitted to the principal/designee. See reverse side before completing. PART A: ACCIDENT INFORMATION Injured iNJUR Date of birth
Last First MI

Home address Street School name Home phone no. /

City

State

ZIP Code

School number

Grade

Age

Sex: M Male M Female Date of accident Date accident reported Specific activity Describe accident Was an adult present at scene of accident? PART B: INJURY INFORMATION Nature of injury / /

Time of accident

M a.m. M p.m.

Type of activity

Choose one.
Location of accident

Choose one.

Choose one.

M Yes M No

Name of Individual

Choose one.

Part(s) of body

Choose one.

Choose one.

Choose one.

Immediate Action Taken First aid:

M Yes M No, By Whom M Yes M No, By whom

Sent to health room: Sent to doctor:

M Yes M No, By whom

Doctors name Sent back to class: Sent to hospital:

M Yes M No, By whom

M Yes M No, By whom

Name of Hospital Notified Parent/Guardian or Neighbor: How notified If Yes, Date Notified / / Time Notified . : M a.m. M p.m. Student has accident insurance

M Yes M No, By Whom

Total number of days lost from school PART C: AUTHORIZATION

M Yes M No

MCPS Form 525-2, 12/08

Signature, Principal

/
Date

DISTRIBUTION: COPY 1/Employee and Retiree Service Center; COPY 2/Retain

INSTRUCTIONS FOR COMPLETING THE STUDENT ACCIDENT REPORT FORM GENERAL Complete all of the questions and the authorization section. If not complete the form will be returned. Send the original within two weeks to The Employee and Retiree Service Center. Keep one copy for your files. Examples of reportable accident reports are: All injuries to the head, eye, neck or spine, any bone or joint injury that results in swelling; any puncture wound, burn or laceration that looks as though it may require sutures, ingestion of any drug, chemical, or foreign materials, or any animal bite. Refer to MCPS Regulation EBH-RA: Reporting Student Accidents. PART A: ACCIDENT INFORMATION Complete as indicated. Grade. Indicate the grade level such as 01, 02, 03 ... 12 for Grade 112. Head Start should be shown as 24, Kindergarten as 25, Special Education as 26, and Ungraded as 27. Age. State age of student on last birthday. Sex. Indicate M for male and F for female. Date of Accident. Indicate per example: 06/10/91 = June 10, 1991. Time of Accident. Indicate the exact time the accident occurred per example: 02:10 = Ten minutes past two oclock. Check whether a.m. (Morning) or p.m. (Afternoon).Date Accident Reported. Indicate per example: 06/21/02 = June 21, 2002. Type of Activity. Indicate using one of the following codes:
01 Elementary Physical Education 02 Elementary Noon Recess 101 102 103 104 105 106 107 108 Archery Badminton Balance Beam Baseball Basketball Cheerleader Dance Dodge Ball 109 110 111 112 113 114 115 116 03 Elementary Nonphysical Ed. and Non-noon Recess 04 Secondary Physical Education 117 118 119 120 121 122 123 124 Parallel/Horizontal Bars Physical Fitness/Calisthenics Rings/Ropes Skating Ice/Roller Skiing Slides and Seesaw Soccer/Field-Ball Softball 215 216 217 218 219 220 221 125 126 127 128 130 131 132 133 05 Secondary Non-Physical Ed. 06 Varsity & Junior Varsity

Specific Activity. Indicate using one of the following codes:

Fencing Field Hockey Football Games Golf Jungle Gym Kickball Muscleman 208 209 210 211 212 213 214 Swimming 134 Wrestling/Self Defense Swings Tennis Track and Field Tumbling Vaulting Box Volleyball Weight Lifting and Training

Location of Accident. Indicate using one of the following codes:

201 All Purpose Room 202 Athletic Field 203 Auditorium, Stage 204 Bicycle 205 Cafeteria 206 Classroom 207 Corridor Grounds/Nonplayground Gymnasium and Auxiliary Gym Home Arts Industrial Education Shops Laboratories Lavatory Library Locker Room 222 Special Activities (Field Trips, Motor Vehicle Clubs, Class Trips, etc.) Music and Band Room 223 Stairs Outdoor Ed. Site 224 Swimming Pool Pedestrian 225 Conference Room Playground 226 Career Programs/Off Campus School Bus

Description of Accident. Briefly describe how the accident occurred. Was an Adult Present at Scene of Accident. Check Yes or No. Name of Individual. Print the individuals full name. PART B: INJURY INFORMATION The information in this section is not intended to elicit a medical diagnosis, but is used for statistical purposes. Nature of Injury Indicate using one and not more than three of the following codes that best describe(s) the injuryfinjuries.
37 Abrasion/Bruise 23 Amputation 25 Asphyxiation 38 Bite 32 Burns/Scalds/Chemical 24 21 28 27 33 Concussion Death Dental Dislocation Electrical Shock 31 26 22 29 34 Foreign Body Imbedded/Loose 35 Object in Mouth/Poisoning Fracture/Chipped 30 Puncture Internal Injuries 36 Sprain/Strain/Pulled Muscle/ Laceration/Cuts Torn Ligament Eye

Part of Body Indicate using one and not more than three of the following codes. If more than three parts of the body have been injured, indicate the most serious.
69 65 55 60 57 Ankle Arm Back Chest/Ribs Ear 68 53 56 75 71 Elbow Eye Face Fingers/Thumb Foot 62 72 52 63 51 Genital Area Hand Head Hip Internal Organs 66 67 58 54 59 Knee Leg Mouth/Lips/Tongue Neck/Throat Nose 64 61 73 74 70 Shoulders/Collar Bone Stomach Teeth Toes Wrist

First Aid Check Yes or No. If Yes is checked, indicate who gave the student first aid (nurse, secretary, etc.). Sent To Health Room. Check Yes or No. If Yes is checked, indicate who sent the student to the health room (secretary, teacher, etc.). Sent to Doctor. Check Yes or No. If Yes is checked, indicate who sent the student to the doctor (secretary, teacher, nurse, etc.). Print the doctors name. Sent Back to Class. Check Yes or No. If Yes is checked, indicate by whom. Sent to Hospital. Check Yes or No. If Yes is checked, indicate who sent the student to the hospital (nurse, teacher, etc,). Print the Hospitals name. Was Parent, Guardian, or Neighbor Notified. Check Yes or No. Date Notified. Indicate date per example: 05/2/02 = May 21, 2002. How Notified. By telephone, etc. Time Notified. Indicate the exact time per example: 10:50=10 minutes before 11 oclock. Check whether a.m. (morning) or p.m. (afternoon). By Whom. Print full name of person who notified the parent or guardian. Total Number of Days Lost from School. Indicate per following examples: 000.5= day; 001.0=1 day; 100.0=100 days; 023.5=23 days. Student Has Accident Insurance. Check Yes or No. PART C: AUTHORIZATION This form must be signed by the Principal. Also indicate the date this report was signed.