HBUHSD Injury, Illness, & Incident Report

HBUHSD Injury, Illness, and Incident Report

This Injury/Illnes/Incident Report must be completed when there is an injury, illness, or incident at any school site, or field trip ativity. This report should be immediately completed by school staff when an employee, student, or guest experiences an injury or illness, or if an incident occurs on District property, or at a school event. Immediately contact HBUHSD Risk Services at (714) 903-7000 ext. 50370, or [email protected] if you have questions. This form may contain informaton relating to an individual's health and must be used in a manner that protects the confidentiality of the indivdual while informaton contained therein isused for safety/health purposes.

Please complete the form below. Required fields are marked with an asterisk*

INFORMATON ABOUT THE INJURED PERSON(S)

Name of Injured Person(s):*

Answer Required

Affiliation*

Answer Required

Employee

Student

Other:

Job Title (If Applicable)

Answer Required

District Location Worked (If Applicable)

Answer Required

Home Address*

Answer Required

Phone*

Number Required

DOB*

Answer Required

Gender*

Answer Required

Female

Male

Other

Prefer not to say

Student ID # (If Applicable)

Answer Required

Driver's License #

Answer Required

DETAILED INFORMATOIN ABOUT INJURY / ILLNESS / INCIDENT

Location where the incident occured:*

Answer Required

Date of Occurence:*

Answer Required

Time of Occurence:*

Answer Required

If an employee was injured, what time did they start work?

Answer Required

Was the injury / illness / incident reported to a School Supervisor or Administrator?*

Answer Required

Yes

What was the individual(s) doing just before the injury / illness / incident occurred?*

Answer Required

Please describe, in detail, what happened:*

Answer Required

If any unsafe condition or behavior occurred at the time of the injury / illness/ incident, please describe in detail:*

Answer Required

Were other individuals injured in this incident? If yes, please name:*

Answer Required

Were there any witnesses to the incident? If yes, please name:*

Answer Required

Please upload any photos or videos taken of the incident:

Answer Required

Choose a file or drag it here.

TREATMENT INFORMATON

Name of physician, school nurse, or other care provider that rendered any form of medical treatment to the individual after illness / injury / incident:

Answer Required

If medical treatment was provided off school/district property, where was it provided?

Answer Required

Does the injured party have insurance?*

Answer Required

Yes

Other:

If yes, with what provider?

Answer Required

Was the individual treated in an emergency room?*

Answer Required

Yes

If yes, where?

Answer Required

Was the individual formally admitted into the hospital?*

Answer Required

Yes

ADDITIONAL INFORMATION (or) WITNESS NARRATIVE STATEMENTS

Additional Information:

Answer Required

Additional supporting documents:

Answer Required

Choose a file or drag it here.

Name of the individual completing the form:*

Answer Required

Title:*

Answer Required

Contact information (Phone Number and/or Email):*

Answer Required

Huntington Beach Union High School District

Please fix the highlighted areas below before submitting.

HBUHSD Injury, Illness, & Incident Report