Client Injury Report

Date / Time of Injury *

Date

Time

Client's Abbreviation *

Learner's initials: for example Holly Bennett is HoBe

Nature of Injury: *

Other Nature of Injury: *

Place of Injury *

Clinic Injury *

Other Place of Injury: *

Kind of Accident *

Struck by what/whom: *

Other Kind of Accident: *

Part of Body Injured *

Head Injuries: *

Trunk Injuries: *

Arm Injuries *

Leg Injuries *

Treatment: *

Other Treatment Provided: *

Witnesses *

Highly Detailed Description of Event: *

Was Parent / Guardian informed? *

Date / Time of notification *

Date

Time

Notified by: *