Lower Council High School
Lower Council School District
STUDENT ACCIDENT REPORT FORM
Instructions: This form must be completed for any accidents involving a student during school hours or occurring during the hours before and after school hours when students are known to be on school property. This form should also be used for incidents off school property when the incident occurs during a school-sponsor event. This form, when completed, should be filed in the Office of the Vice Principal.
Staff completing Report: Ron Clemmons, Bus Driver
Date and Time of Incident: April 3, 2011 at 3:20 p.m.
Location of Incident: ___School building __School grounds X School bus
___Other (provide detail here)
SECTION ONE – STUDENT INFORMATION
Name: Davis Hilary Sex: M F Age: 15 Grade: 10th
Home Address: 334 Wireman Road Apt 3A, Lower Council, New State 03900
SECTION TWO – ACCIDENT
1. Describe the accident in detail:
Student was prevented from exiting the school bus at his usual stop by Bobby Jones, an 11th grader who held him down and threatened him according to witnesses. One witness, a younger student named Melissa, claimed that she observed a knife in Bobby’s hand.
2. Describe the student’s activities at the time of the accident:
The student was attempting to exit the school bus.
3. What was the location of the accident?
The accident occurred on the School Bus as it was on the home-bound route.
4. Identify the student’s injuries in detail:
The student suffered cuts and bruises and seemed hysterical. He was crying loudly and bleeding.
5. Was anyone else injured in this incident? (If so, a separate form must be completed for each person injured.)
Yes___(If yes, what are the names of the other injured individuals?)___________________
6. Person in charge when accident occurred (Name and Title):
Ron Clemmons, Bus Driver
7. Actions taken following the accident:
Bobby Jones was removed from the bus by police and restrained. A search was conduct by the school nurse and no knife was found on Bobby Jones. He was then taken back to the high school.
8. If the student was sent to the hospital:
· Was the student taken to the hospital by ambulance? Yes No
· If so, name of person who called for the ambulance: Not applicable
· If no ambulance was called, identify who transported the student to the hospital: Not applicable
· Name of hospital: Not applicable
· Other medical treatment provided: The victim’s mother indicated that she was taking him to his pediatrician after she picked him at the incident site.
9. Identify who notified the student’s parents, the time of the notification and the result:
Davis’s classmate, Melissa Jones called his mother who arrived at the scene of the incident immediately.
10. Other information relevant to this incident:
Ron Clemmons, Bus Driver
Signature and Tile