Accident Report

An Accident Report should be completed for any incident resulting in injury (whether minor or major) occurring on the property of Saint Elizabeth Ann Seton Catholic Church or any offsite activity that is sponsored by Saint Elizabeth Ann Seton Catholic Church. This report should be completed within 24 hours of the incident.

If you have any questions, please contact the Business Manager, Jennifer Engquist, in the parish office.
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- Member Name REQUIRED Please fill out this field. Please enter valid data.
- Parish/School REQUIRED Please fill out this field. Please enter valid data.
- Address REQUIRED Please fill out this field. Please enter valid data.
- City REQUIRED Please fill out this field. Please enter valid data.
  
  State REQUIRED Please fill out this field.
  
  Zip REQUIRED Please fill out this field. Please enter a zip code.
- Phone Number REQUIRED Please fill out this field. Please enter a phone number.
- Email Please enter an email address.
- Person Reporting Accident REQUIRED Please fill out this field. Please enter valid data.
- Date Form Completed REQUIRED Please fill out this field. Please enter a date.
- Date of Accident REQUIRED Please fill out this field. Please enter a date.
- Time of Accident REQUIRED Please fill out this field. Please enter valid data.
- Where Accident Occurred REQUIRED Please fill out this field. Please enter valid data.
- Were photographs taken? REQUIRED Yes No Please fill out this field.
- Describe Accident REQUIRED Please fill out this field.
- Other Person(s) Involved - Name Please enter valid data.
- Student? REQUIRED Yes No Please fill out this field.
- If Student, Parent Name Please enter valid data.
- The following is for the parent's information.
- Address Please enter valid data.
- City Please enter valid data.
  
  State
  
  Zip Please enter a zip code.
- Phone Number Please enter a phone number.
- Work Number Please enter a phone number.
- Date of Birth REQUIRED Please fill out this field. Please enter a date.
- Injury/Damage REQUIRED Please fill out this field. Please enter valid data.
- Transported by ambulance? REQUIRED Yes No Please fill out this field.
- Witnesses (Please include address and phone number)
- Comments
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St. Elizabeth Ann Seton

Catholic Church

Accident Report

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