GMG Incident Report - DOC - DOC

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					                          GMG Incident Report
               GMG Elementary School                       GMG Jr./Sr. High School
               1710 Wallace Avenue                         306 Park Street
               Green Mountain, IA 50632                    Garwin, IA 50632


Date of Incident: ____________________                             Approximate Time: _________
       _____ Accident                       _____ Injury           _____ Property Damage
1. Please describe the nature of the incident: _____________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Please report what action was taken: _________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3. Student’s Name(s): __________________________________ Grade: ___________
4. Were the parents notified: _____ No ____ Yes, by whom? _______________________
                                                When: __________________________
5. Was any immediate or emergency treatment needed?                _____ Yes ____ No
6. If yes, what was the treatment that was needed? ________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
7. Describe the nature of the student’s injuries: __________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
8. Is a medical release needed to return to activities?          _____ Yes ____ No
9. Who were the school personnel supervising? ___________________________________
10. How/When was a school official notified? _____________________________________

__________________________________________                         __________________
                         Signature                                         Date



__________________________________________                         __________________
                   Principal’s Signature                                   Date



           Please place any additional information on the back of this form


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