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Accident Report

Accident Report
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Your name
required
Your email address
required
District Name
required
Laurel School District 7-70
Other
School Name - Out of District
required
School Name
required
No results found
Elementary School
Intermediate School
Laurel Middle School
Laurel High School

South Elementary Principal: Katherine Dawe

Email: katherine_dawe@laurel.k12.mt.us

South Elementary Phone number: (406)628-3380

West Elementary Principal: Bethany Fuchs

Email: bethany_fuchs@laurel.k12.mt.us

West Elementary Phone number: (406)628-3400

Graff Elementary Principal: Lynne Petersen

Email: lynne_petersen@laurel.k12.mt.us

Graff Elementary Phone number: (406)628-3450

Laurel Middle School Principal: Justin Klebe

Email: Justin_klebe@laurel.k12.mt.us

Laurel Middle School Phone number: (406)628-3900

Laurel Middle School Vice Principal: Allyson Robertus

Email: allyson_robertus@laurel.k12.mt.us

Laurel Middle School Phone number: (406)628-3900

Laurel High School Principal: Stacy Hall

Email: stacy_hall@laurel.k12.mt.us

Laurel High School Phone number: (406)628-3500

Laurel High School Vice Principal: John Stilson

Email: john_stilson@laurel.k12.mt.us

Laurel High School Phone number: (406)628-3500
Principal's Name
required
School Phone
required
Date of Accident
required
Time of Accident
required
Supervising Employee Name
required
Claimant's First Name
required
Claimant's Middle Initial
Claimant's Last Name
required
Claimant's Address - City
Claimant's Address - State
Claimant's Address - Zip Code
Claimant's Social Security Number
Home Phone Number
Claimant's Age
Claimant's Date of Birth
Claimant's Sex
required
Male
Female
Claimant's Grade
required
Parent's Name (if student)
Parent's Work Phone Number
Nature of Injury
required
Bite
Bruise
Burn
Concussion
Cut/Puncture
Dislocation
Fracture
Head Injury
Scratch
Sprain/Strain
Other
Place of Accident
required
Athletic Field
Bathroom
Cafeteria
Classroom
Gymnasium
Hallway
Parking Lot
Playground
Sidewalk
Stairs
Other
Body Part Injured
required
Ankle
Arm
Back
Eye
Face
Finger
Foot
Hand
Knee
Leg
Neck
Nose
Shoulder
Teeth
Wrist
Other
Describe accident and injury in detail (attach additional description as necessary)
required
Additional Description (optional)

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Were efforts made to contact the parent/guardian about the accident?
required
Yes
No
Was first aid administered?
required
Yes
No
Who administered first aid?

Optional
Where was the student sent?
required
Home
To Physician
To Hospital
Staying at School
Is student covered by Student Accident Insurance?
Yes
No
If yes to the question above, please list Company Name, Address and Phone Number

If medical or hospital treatment was required, please complete the following information.

(Attach a copy of medical bills, if available.)
Name and address of doctor or hospital
Copy of medical bills

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Witnesses
Name
Address
Phone
Signature of Person Completing the Report
required
Draw your signature in the area above, or use the saved signature button if available.
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