Medicine Valley Public Schools

Injury Report

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Student Information:

Student Name:	Date:	Sport/Location:
Student Phone Number:	Grade: K First Second Third Fourth Fifth Sixth Seventh Eighth Ninth Tenth Eleventh Twelfth

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Description of Injured Area:

Type of Injury:	Concussion Dislocation Fracture Separation Sprain Strain Wound Other	Injured Area:	Left Right
		Location:	Ankle Arm Back Calf Elbow Eye Foot Hand Head Hip Knee Leg Neck Shoulder Thigh Wrist Other

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Immediate Treatment:

History:

Evaluation:

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Did You Contact:

Doctor: Parents:Other:

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Teacher Name: