Incident-Injury Report Forms
Incident/Injury Reporting Procedures
There are three (3) separate incident forms to be used depending on the injured individual:
- Student Incident/Injury Report
- Employee Incident/Injury Report
- Non-Employee Incident/Injury Report
When submitting any incident form, the form must be completed in its entirety. The recommended corrective action portion must be completed by an administrator to prevent the incident from occurring again. This is not medical attention recommended by the nurse. If no corrective action is warranted, please indicate by writing “N/A”. The form must be signed by an Administrator. A copy of all incident reports and claims should be submitted to the Business Office to the attention of Annette Giordano. Incomplete incident forms or an old form will be returned to an Administrator.
If further medical attention is recommended for a student, you must send the student home with the BMI Benefits accident claim form with part 1A to be completed by a district employee ( in most cases the school nurse). A copy of the Student Incident/Injury Report along with a copy of the BMI Benefits accident claim form should be forwarded to the Business Office.
If medical attention is recommended for an employee, Qual-Lynx is to be notified at 1-800-425-3222 and must be noted on the Employee Incident/Injury Form. A copy of the Employee Incident/Injury Form should be forwarded to the Business Office.