If your child takes any medication at school (inhalers, Epi-pen, Tylenol, etc.) please fill out the forms below and return to the front office.

Accident Report Form

Name of person preparing report

First Name

Last Name

Date

YYYY

Time

Hour

Minute

Second

Description of Incident:

(please be as detailed as possible with factual information including location and nature of incident)

Witnesses

First aid given

Describe first aid given

Was an individual taken to the hospital?

Name of individual taken to the hospital.

Was an individual taken to a doctor?

Did individual involved refuse treatment

St. Mary’s Catholic School

1101 East 5th St.