Accident and/or Injury Report Form

Your name *

Email address *

Phone number *

Date of Accident: *

Time of Accident: *

Ex: 3:45 PM

This accident was *

Name of injured person: *

Phone number for injured person: *

Email for injured person: *

Address of injured person: *

Birthdate *

Age of injured person *

min: 1 / max: 99

(numbers only, Ex: 10)

Specific location of accident: *

Describe the accident: *

What action was taken by HUMC? *

(select all that apply)

Minor treatment: ice, band-aid, bandage, etc

Sent home

Recommended to see a Dentist

Recommended to see a Physician

Sent to Dentist

Sent to Hospital

Further details about action taken by HUMC:

If applicable, how and when was the parent (or guardian) notified?

Person #1 who witnessed the accident: *

(Name & email address)

Phone number *

Person #2 who witnessed the accident: *

(Name & email address)

Phone number *

Any pertinent notes or details to add?

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.