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Incident Report – Students/Teachers or Visitors – non WCB (excluding CTS Teachers)

Corporate Risk Management

Conditions: Complete form in full andFAX within 24 hours to 403-294-8458.
PLEASE TYPE THIS REPORT
For bodily injury to employees, CTS Teachers and volunteers use the Employee/Volunteer Incident Report
For incidents involving motor vehicles use the Vehicle Incident Report
For incident involving Property Damage use the Accident/Vandalism Report

Severity of Injury (please indicate one of the following):

High (ambulance needed)Medium (medical attention recommended)Low ( minor first aid)

Name of Injured Person: / Student DOB: / Grade of student:
Is the injured person a: / Student / Teacher / Visitor
School: / School Phone:
Incident Date: / Time: / Location of incident - Specify
Name & Telephone of Parent/Guardian: / Notified of incident? Yes No
Please describe how the incident happened (use a separate sheet if necessary)
What comments/instructions were given by the parent/guardian when contacted (include the information given, and the response):
Activity at the time of the incident (e.g. football, field trip, phys. ed., etc.) :
What injury did the person sustain? (e.g. arm broken, puncture leg wound, chipped tooth)
Was First Aid Provided? Yes No List All Providers
Name of First Aider and Qualification / Was Outside Medical Aid Required? Yes No List All Providers
Name of Provider and Qualification
Name of First Aider and Qualification / Name of Provider and Qualification
Treatment provided: (Use additional paper if necessary)
Please indicate the type of transportation (if any) used: None Ambulance Parent Other
Transported to:
Please list any witnesses to the incident:
Name: Telephone: / Name: Telephone:
Please identify:
Who prepared this report: The supervisor at time of incident:
(please print)Title: (please print)Title:
Name of Principal: Principal Signature: Date:
(please print)
Personal information is collected under the authority of Alberta’s Freedom of Information and Protection of Privacy Act (FOIP), the School Act, and the Insurance Act. This information will be used to investigate incidents for loss control measures and for insurance reporting requirements. This information will be treated in accordance with the privacy protection provisions of the FOIP Act. A copy of this report may be released to the Calgary Board of Education’s Insurance Broker on a need to know basis. If you have any questions about the collection, contact your school principal or Corporate Risk Management at 294-8551.