Yokohama International School

*Original  to  Student’s  Health  File,  copies  to  Headmaster,  Safety  Director,  Principal  and  Office   Report of Injury

Report of Injury, Illness or Incident Reason for Report: □Injury □Illness □Incident Patient Name: _________________________________ Class:_________ Patient Status: □Student □Faculty/Staff □Parents □Other person Age: (circle) 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Adult Sex: (circle) Male / Female Date: _______________________Time:_____:______AM/PM Type of Injury/Illness: □Allergic reaction □Animal bite/Sting □Bone/joint injury □Burn □Choking □Dental injury □Eye injury □Head injury □Heat/Cold related emergency □Medical Condition ( ) □Psychiatric Emergency □Wound □Respiratory Emergency □Sprain/Strain □Trip / Slip □Others ( )

Body Part Injured: □Ankle (R/L) □Arm (R/L) □Back □Chest □Ear (R/L) □Elbow (R/L) □Eye (R/L) □Face □Finger □Foot (R/L) □Hand (R/L) □Head □Hip□Knee (R/L) □Leg (R/L) □Mouth/Tooth □Nose □Wrist (R/L) □Other ( ) Description of how incident occurred: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Location of Incident: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ First Aid Treatment Required: Y_____ N______ Type of Treatment provided: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ By whom?__________________________ Advised to seek medical treatment? Y_____ N_____ Was hospital care called for or provided? Y _____ N_____ If Yes, Emergency___ Admitted____ How was patient transported: Ambulance_____ Private Vehicle_____ Other_____________ Was the risk of this injury/incident identified in the Risk Management Forms? Y____ N____ If no, please explain ______________________________________________________________________________________________________________________________________________________________________ Full Name and Position of Person Completing Report: _________________________________________ signature:__________________________

                                                                                                                           *Original  to  Student’s  Health  File,  copies  to  Headmaster,  Safety  Director,  Principal  and  Office  

☆ Please give a detailed written report on the timeline of the event, the accident and

actions taken.

☆ Describe any action that has since been taken or perhaps could be taken to prevent a similar accident

☆ Any other comments or observations?