School Staff Student-Related Injury Compensation Form
Staff Information
Full Name
Staff ID
Position
Department
Incident Details
Date of Incident
Time of Incident
Location
Brief Description of Incident
Injury Details
Name of Student(s) Involved
Nature of Injury
Medical Treatment Provided (if any)
Compensation Claim
Expenses Incurred (if any)
Additional Details Regarding Claim
Staff Signature
Name
Date