Accident & Incident Report

The accident and incident report forms have been amalgamated; fields will enable depending on the boxes selected. This report form should only be used for accidents or incidents that involve students.

If a workplace injury has impacted an employee or contractor's ability to work, please email HR at hr@kccsociety.ca and cc: the Academic Head of School at skraushar@onlineschool.ca. An occupational health & safety representative will respond regarding next steps.

Complete the following fields for primary student involved. If more than one student is involved, please use the Other Students Involved field below:
Student's Name Student's Name First Last
Student's Grade
Student's Grade (Archived)
Other Students Involved
If multiple students are involved, please submit 1 report and include their first name, last name, teacher's name, and student's grade here. For example:
- John Smith - Alison Wang, Grade 6
- Jane Montgomery - Matthew Abbott, Grade 4
Staff or Contractors Involved

Staff or Contractors Involved Case Manager/ Teacher LG Coordinator Education Assistant (EA) Staff Other(s) N/A
Case Manager/Teacher Name Case Manager/Teacher Name First Last
LG Coordinator LG Coordinator First Last
Education Assistant (EA) Name Education Assistant (EA) Name First Last
Other(s) Name and Role
Staff Name Staff Name First Last
Region

Region Flex Interior Island North Lower Mainland
Complete the following fields for the primary student involved:
Is this student a part of Inclusive Education?

Is this student a part of Inclusive Education? Yes No Unknown
Is this student a part of Learning Support?

Is this student a part of Learning Support? Yes No Unknown
K-9 Support Teacher, if known K-9 Support Teacher, if known First Last
Education Assistant (EA), if known Education Assistant (EA), if known First Last
Case Manager, if known Case Manager, if known First Last
Grad Advisor, if known Grad Advisor, if known First Last
Please provide specific information regarding the situation:
Is this situation an?

Is this situation an? Accident Incident Inactive Grad Student

Accident Report Form: used for any accident that involves a student and results in injuries, anaphylaxis, or medical situations etc.

Incident Report Form: used for any one-time behavioural or interpersonal situations that may have ongoing ramifications for those involved.
Date Date / MM / DD YYYY
Time Time : HH MM AM/PM
Location
Describe in detail where the accident occurred

Example: In the gym of Abby E-Free church during PE class or on the bunny hill of Hemlock mountain.
Describe in detail how the accident occurred

Note: Report factual statements and observations only. Attach a sketch or diagram if it may be helpful to describe the situation.
Describe any physical injuries and treatment that was required for this accident.

Example: Type of injury and body part affected.
Did this accident occur at a place of work that the student was using towards course credit?

Did this accident occur at a place of work that the student was using towards course credit? Yes No
Was First Aid rendered?

Was First Aid rendered? Yes No
First Aid Responder's Name First Aid Responder's Name First Last
First Aid Responder's Name Phone First Aid Responder's Name Phone - ### - ### ####
Was an ambulance called?

Was an ambulance called? Yes No
What time did the ambulance arrive? What time did the ambulance arrive? : HH MM AM/PM
Were parents/guardians contacted?

Were parents/guardians contacted? Yes No
Time: Time: : HH MM AM/PM
Name of Witness(es)
Describe the situation in detail.

Be specific and include information regarding, context (who, what, when, and where), expectations and other relevant variables.
Describe the action plan.

Note: List the steps taken to address the situation. Be specific regarding all accommodations, modifications, and supports.
Follow Up

Modify action plan, as needed, to accommodate the situation.
Upload photos if available:

Attach Files
Submitted By Submitted By First Last
Email for Confirmation
Phone Phone - ### - ### ####
Date Date / MM / DD YYYY