SECTION 7.02 INJURY REPORTS Contact: Finance @ Extension 4150 A. Overview An Injury Report is to be completed in ink by District personnel only any time a student or person other than an employee is injured on Everett Public Schools property. Do not allow student or parents/injured party to complete. Do not use this form to report employee (on the job) injuries. Complete and forward this form to the Finance Department, Risk Manager within 24 hours of the incident. If an accident occurs that is critical in nature, please call the phone number listed at the top of the form and report the accident verbally. Describe the incident in sufficient detail to show the conditions that existed at the time of the incident. Forms are available in the office of each Principal or Building Manager and at the Finance Office. B. Guidelines Following are guidelines to assist you in determining when to complete an Injury Report form. All student injuries where 911, EMT or other outside medical assistance is called to the scene. All student injuries where the student is taken from school or a school event to a physician or hospital either by the school or by a parent or guardian. Student injuries involving the head, neck or back, other than minor scrapes or bruises. Student injuries that occur in the shop (wood or metal), weight room, Physical Education class and athletic events, other than minor scrapes or bruises. Playground injuries, other than minor scrapes or bruises. Injuries that involve a defect in playground equipment, or other school equipment, or in school facilities (actual or perceived). Student injuries that involve burns from any source, or electrical shock. Student injuries involving exposure to, ingestion of, or contact with chemicals. Student seizures, whether related to trauma or medical condition. NOTE: It is important to specify what action was taken by school personnel in dealing with the seizure. All drug-related incidents, whether overdose or reaction from prescription drugs or illegal substances. All student incidents involving loss of consciousness. (Students suffering from a loss of consciousness should be examined by a physician.) All student incidents where a student goes into shock. Student injuries involving entering, exiting, or while riding on a school bus, other than minor scrapes or bruises. All injuries or complaints involving significant privacy issues of students. (Call Washington Schools Risk Management Pool at 206-394-9737.) Rev. 02/06 Section 7.02 Page 1 of 2
INJURY REPORTING FLOWCHART EVERETT PUBLIC SCHOOLS INJURY OCCURS An individual(s) is injured while on District property or at a District sponsored event. NOTIFICATION Immediately notify the building administrator and support staff for first aid assistance and reporting guidelines. MEDICAL ASSISTANCE Provide immediate assistance to the injured individual(s). Contact building First Aid Team and, if necessary, call 911. (Note: Error on the side of caution when treating the individual(s) as they may verbally minimize their injury due to embarrassment or pride.) PROCESSING REPORT OF INJURY Building administration coordinates submittal of applicable injury reporting forms. STUDENTS/VOLUNTEERS/CITIZENS Including student teachers and persons working on contract for the District (OP/PTs, SROs, Durham). DISTRICT EMPLOYEES Employees including substitutes and coaches. COMPLETE AN INJURY REPORT FORM Available through building administration. (Section 7.01 - Business Information Manual) Form to be completed by designated District staff members only. For assistance contact Finance. PROVIDE EMPLOYEE WITH AN EMPLOYEE INJURY PACKET Available through building administration. Packet includes employee instructions for on-the-job injuries. Site staff is trained to review processes. For assistance contact Human Resources. FORWARD COMPLETED FORMS TO: Finance Longfellow Building 425-385-4150 Note: The District is self-insured for injuries to students, volunteers and citizens through the Washington Schools Risk Management Pool. FORWARD COMPLETED FORMS TO: Human Resources Longfellow Building 425-385-4100 Note: The District is self-insured for employee on-the-job injuries through the Puget Sound Workers Compensation Trust. Rev. 02/06 Section 7.02 Page 2of 2
INJURY REPORT EVERETT PUBLIC SCHOOLS FINANCE DEPARTMENT LONGFELLOW BUILDING STUDENT/VOLUNTEER/CITIZEN ~ INCIDENT/ACCIDENT REPORT FORM THIS FORM DOES NOT COMPLY WITH RCW 4.96.020 FOR THE FILING OF A CLAIM FOR DAMAGES FORM INSTRUCTIONS: This form to be completed by DISTRICT PERSONNEL ONLY any time a student or person other than an employee is injured on Everett Public Schools property. Do not allow student or parents/injured party to complete. Do not use this form to report employee (on the job) injuries (Contact Human Resources at 425-385-4115). Complete and forward this form to the Finance Department, Risk Manager within 24 hours of the incident. If an accident occurs that is critical in nature, please call the Finance Department, Risk Manager at 425-385-4150 and report the accident verbally. Describe the incident in sufficient detail to show the conditions that existed at the time of the incident. GENERAL INFORMATION SCHOOL DISTRICT: Everett Public Schools SCHOOL NAME: DISTRICT CONTACT: Jeff Moore or Kim Walker PHONE NUMBER: 425-385-4150 INCIDENT/ACCIDENT DATE: TIME: AM/PM LOCATION: CLASSROOM PLAYGROUND GYM LABORATORY SHOP OFF-PREMISES OTHER, SPECIFY: DESCRIPTION OF ACCIDENT/CAUSE OF INJURY: WITNESS(ES): WITNESS(ES): IDENTIFY AGENCY CALLED TO SCENE (police, fire, etc): PHONE NUMBER: PHONE NUMBER: REPORT NUMBER: INJURIES (complete separate form for each injured individual) FOR EMPLOYEE INJURIES CONTACT HUMAN RESOURCES AT 425-385-4115 NAME: STUDENT CITIZEN LAST FIRST MI ADDRESS: GENDER: AGE: GRADE: STREET CITY ZIP CODE NAME OF PARENT/GUARDIAN (if applicable): HOME PHONE: ADDRESS OF PARENT: WORK PHONE: PART OF BODY INJURED: TYPE OF INJURY (e.g., cut, burn): CELL PHONE: EXTENT OF INJURY (e.g., minor, severe): NO. OF SCHOOL DAYS LOST: IF CITIZEN, REASON FOR BEING AT SCHOOL/FACILITY: PERSON IN CHARGE AT TIME OF INCIDENT: TITLE: PHONE #: ACTION TAKEN: BY WHOM/WHEN: PRESENT AT SCENE? YES NO SENT TO HEALTH ROOM SENT HOME 911 CALLED SENT TO HOSPITAL/DOCTOR IF STUDENT, ACCIDENT. INS? YES NO STUDENT FELT WELL AND RETURNED TO CLASS AFTER MINUTES OF OBSERVATION ADDITIONAL INJURY INFORMATION: PARENT/GUARDIAN NOTIFIED: PHONE #: WHEN NOTIFIED: BY WHOM: BUMPS OR BLOWS TO THE HEAD - SYMPTOMS: SLIGHT HEADACHE MINOR ABRASION/CUT PALENESS OR FLUSHING WEAKNESS OR PARALYSIS NAUSEA/VOMITING CONFUSION/INCOHERENT BRUISING/SORE LOSS OF CONSCIOUSNESS LOSS OF MEMORY DIZZINESS VISION CHANGES SWELLING AT INJURY SITE BUMPS OR BLOWS TO THE HEAD - TREATMENT: ICE APPLIED BANDAGE APPLIED OTHER (comment): REPORT PREPARED BY: SIGNATURE: BLDG. ADMINISTRATOR SIGNATURE: FOR FINANCE USE ONLY DATE LOGGED: TITLE: DATE: DATE: DATE SENT TO RISK POOL: REV. 08/07 PLEASE SEND THE ORIGINAL TO FINANCE AND KEEP A COPY FOR YOUR RECORDS 7.02a
Injury Report Checklist When to Complete A student or person other than an employee is injured on Everett Public Schools property. How to Complete Form is to be completed by a District staff member only. MINOR BUMP, BRUISE OR BLOW In ink, complete the yellow shaded fields of the Injury Report form. School Name Incident/Accident Date and Time Location of Incident/Accident Description of Accident/Cause of Injury Name of Injured Party Student, Volunteer or Citizen Part of Body Injured Type of Injury Extent of Injury No. of School Days Lost (if applicable) Action Taken Bumps or Blows to the Head - Symptoms (if applicable) Bumps or Blows to the Head - Treatment (if applicable) Log the incident/accident. Retain the Injury Report form at the site. OTHER THAN A MINOR BUMP, BRUISE OR BLOW Injury where 911, EMT or other outside medical assistance is called to the scene. Injured party is taken from school or a school event to a physician or hospital. Injury involving the head, neck or back, other than minor scrapes or bruises. Student injury occurred in the shop (wood or metal), weight room, PE class or athletic event, other than minor scrapes or bruises. Playground injury, other than minor scrapes or bruises. Injury involved a defect in playground equipment, or other school equipment, or in school facilities (actual or perceived). Injury involves a burn, from any source, or electrical shock. Injury involves exposure to, ingestion of, or contact with chemicals. Revised 10/07 Section 7.02 Page 1 of 3
Injury Report Checklist How to Complete (Other than a Minor Bump, Bruise or Blow) Continued Seizure, whether related to trauma or medical condition. NOTE: It is important to specify what action was taken by District personnel in dealing with the seizure. All drug related incidents, whether overdose or reaction from prescription drugs or illegal substances. Incidents involving loss of consciousness. (Students suffering from a loss of consciousness should be examined by a physician.) All incidents of shock. Student injury involving entering, exiting, or while riding on a school bus, other than minor scrapes or bruises. Any student injury or complaint involving significant privacy issues. In ink, complete the green shaded fields, in addition to the yellow shaded fields, of the Injury Report form. School Name Incident/Accident Date and Time Location of Incident/Accident Description of Accident/Cause of Injury Name of Injured Party Student, Volunteer or Citizen Part of Body Injured Type of Injury Extent of Injury No. of School Days Lost (if applicable) Action Taken Bumps or Blows to the Head - Symptoms (if applicable) Bumps or Blows to the Head - Treatment (if applicable) Witness(es)/Phone Numbers Identify Agency Called to Scene (police, fire, etc) Report Number Address of Injured Party Gender, Age, Grade of Injured Party Name of Parent/Guardian (if applicable) Home Phone Number If Citizen or Volunteer, Reason for Being at School/Facility Action Taken/By Whom/When Additional Injury Information Report Prepared By/Title/Signature/Date Bldg. Administrator Signature/Date Yellow Green Revised 10/07 Section 7.02 Page 2 of 3
Injury Report Checklist How to Complete (Other than a Minor Bump, Bruise or Blow) Continued Retain a copy of the Injury Report form at the site. Forward the original Injury Report to the attention of the Risk Manager (Finance Department) within 24 hours of the incident/accident. If the incident/accident is critical in nature, verbally report to the Risk Manager at extension 4150. Provide sufficient detail to show the conditions that existed at the time. Immediately forward the Injury Report form. Revised 10/07 Section 7.02 Page 3 of 3