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BOKS Participant Accident FormAll accidents involving injury to children on school premises during the BOKS program must bedocumented and reported. Please complete this form in its entirety. One copy of this form should be kept

for your records. Additional copies of this BOKS accident form should be given to the area coordinator (ifapplicable), the participant and the school nurse as soon as possible.

Date of Accident Time a.m. p.m.

Childs Name Age Sex Grade

Address

School Home Room

Name of Parent/Guardian

Parent/Guardian Phone Number Was parent contacted?

Nature & Extent of Injury

Specific Place of Accident

Description of accident, including cause

Trainer(s) in charge/present at scene of accident

What action was taken?

Were first-aid supplies available? Was any treatment administered? Where?

Did child leave school (or place of accident?) If so, to what destination?

If transported by ambulance, attendant names and escortUnit #:

Names and address of witnesses

Signature of Lead Trainer Date of Report

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