ACCIDENT REPORT FORM (Page 2 of 2)

INJURY / CONDITION / DISEASE DETAILS

INJURY / CONDITION / DISEASE DETAILS

Description of the injury / condition: She was burnt at the chest, left hand and her right foot.
Bodily location of the injury / condition / disease
 Arm – Lower L/R  Arm – Upper L/R  Hand L/R  Finger/s
 Leg – Lower L/R  Leg – Upper L/R  Foot L/R  Toe/s
 Skull  Face  Eye L/R  Nose
 Mouth  Ear L/R  Neck  Shoulder/s
L/R
 Chest  Abdomen  Hip L/R  Internal
Organs
 Back - Upper  Back - Lower  Buttocks  Other

Draw the injuries on the body shape below.

_______________________________________________________________________________
_