Accident Report Form

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Date of Accident(Required)

Time of Accident(Required)

Location of Accident(Required)

Name of Injured Person(Required)

Student ID

Administrator on Duty

First Employee to Respond

Name of Individual Submitting the Report

First Last

Email of Individual Submitting the Report

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Include the nature of the injury and what medical attention, if any, was required or provided at the scene.

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Contact Information

Address
2108 South Horton
Fort Scott, Kansas 66701

Fax: 620-223-4927

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