Incident Report *Reported By: *Your Email Address: Your Phone #: *School: Delano Elementary Delano Intermediate Delano High Community Education *Student Name: *Grade Date of Birth *Date of Incident *Time of Incident *Place of Incident School Building School Grounds To/From School Interscholastic Athletics *Description of Incident Part of Body Injured Ankle Arm Back Elbow Eye Face Finger Foot Hand Head Knee Leg Nose Scalp Tooth Wrist Other Type of Injury Abrasion Amputation Bruise Burn Cut Possible Fracture Laceration Puncture Scratch Sprain Other Witness Name(s) *Treatment Given Yes No First Aid Provided By Type of First Aid Provided Sent Home By Sent to Physician by Name of Physician *Parent/Guardian Notification: Was a parent, guardian or other individual notified? Yes No Name of individual notified By Whom How was the above notified? Follow Up