Saskatchewan School Boards Association
ClaimsPro
Intake
Claim Intake
To clarify the differences between the two forms.
Property And Liability Claim Form is to initiate claims of damages.
(i.e. shattered windows, damaged siding, broken doors)
School Incident Report Form is for reporting incidents of students.
(i.e. students fighting, slip and falls, bodily harm)
All sections highlighted in yellow must be completed.
Intake Progress
Pending Information
Ready To Setup
Property and Liability Claim Form
School Incident Report Form
School Incident Report Form For Insurance Purposes
Injury/Loss Details
Bodily Injury or Loss / Damage to Facility
Injury
Property
1 General
School
Battlefords First Nations High School Joint Board of Education o/a Sakewew High School
Briercrest College and Seminary
Chinook School Division No. 211
Christ the Teacher Roman Catholic Separate School Division No. 212 o/a Christ the Teacher RCSSD No. 212
Conseil des écoles fransaskoises No. 310
Cornerstone Christian School Inc.
Creighton School Division No. 111
Good Spirit School Division No. 204
Holy Family Roman Catholic Separate School Division No. 140 o/a Holy Family RCSSD #140
Holy Trinity Roman Catholic Separate School Division No. 22 o/a Holy Trinity Separate School Division No. 22
Horizon School Division No. 205 of Saskatchewan o/a Horizon School Division No. 205
Ile a la Crosse School Division No. 112
Light of Christ Roman Catholic Separate School Division No. 16 o/a Light of Christ Catholic Schools
Living Sky School Division No. 202 o/a Living Sky School Division No. 202, et al
Lloydminster Public School Division No. 99 o/a Lloydminster Public School Division No. 99
Lloydminster Roman Catholic Separate School Division No. 89 o/a LRCSSD No. 89 a/o Lloyminster Catholic School Division
Luther College, Regina o/a Luther College High School
Lutheran Collegiate Bible Institute o/a LCBI High School
North East School Division No. 200 o/a North East School Division
Northern Lights School Division No. 113 of Saskatchewan
Northwest School Division No. 203 o/a NWSD #203
Prairie South School Division No. 210 of Saskatchewan o/a Prairie South School Division No. 210
Prairie Spirit School Division No. 206
Prairie Valley School Division No. 208 of Saskatchewan o/a Prairie Valley School Division No. 208
Prince Albert Roman Catholic Separate School Division No. 6 o/a Prince Albert Catholic Schools
Regina Public Schools Division No. 4 of Saskatchewan o/a Regina Public School Division a/o Regina Public Schools
Regina Roman Catholic Separate School Division No. 81 o/a Regina Catholic Schools
Saskatchewan Rivers School Division No. 119 o/a Saskatchewan Rivers Public School Division No. 119
Saskatchewan School Boards Association
Saskatoon Christian School, incl. Portables
Saskatoon Public Schools Division No. 13 of Saskatchewan o/a Saskatoon Public Schools
South East Cornerstone School Division No. 209 of Saskatchewan o/a South East Cornerstone Public School Division
St. Paul's Roman Catholic Separate School Division No. 20 o/a Greater Saskatoon Catholic Schools
Sun West School Division No. 207 o/a Sun West School Division
Name and Address of School
Date of Incident
Time of Incident
Telephone #
Description of how Incident Occurred
Add Injured Person
Subscreen
Name Code
First Name
Last Name
Age
M/F
Address
Postal Code
Grade/Year/Night School
Student/Visitor/Other: (explain)
Division/Program (schools only)
Parent/Guardian/Emergency Contact
Telephone #
Notified?
How?
Parent/Guardian/Emergency Contact Instructions
Emergency Treatment
What?
By Whom?
Advised to Seek Medical Treatment
Where?
Hospitalized Overnight?
How Transported?
Add Witnesses
Subscreen
Name Code
First Name
Last Name
Teacher/Instructor/Other
Witness Activity at Time
Location of Incident
L01 - Basement
L02 - Cafeteria/Lunchroom
L03 - Classroom
L04 - Shops/Lab/Kitchen
L05 - Doors/Entrance Areas
L06 - Dormitories
L07 - Gymnasium/Auditorium
L08 - Hallways/Lockers
L09 - Library/Office/Lounge/Study Room
L10 - Park/Grounds
L11 - Parking Lot
L12 - Playing Fields
L13 - Playground Equipment
L14 - Pool
L15 - Rink
L16 - Sidewalks/Roads Off Facility Property
L17 - Stairs with Building
L18 - Stairs/Sidewalks within Grounds
L19 - Washrooms/Changing Rooms/Showers
L20 - Other - (please explain)
Location of Incident - Other
SECTION A
Nature of Injury/Damage
N01 - Bruise/Abrasion/Swelling
N02 - Burn
N03 - Concussion (suspected)
N04 - Crushed
N05 - Dental Damage
N06 - Dislocation
N07 - Fatality/Death
N08 - Fracture
N09 - Imbedded Object
N10 - No Information
N11 - Nosebleed
N12 - Open Wound / Laceration
N13 - Sprain/Strain (suspected)
N14 - Winded
N15 - Property DMB / Other Party
N16 - Bites/Stings
N17 - Other - (please explain)
Body Area (Injury)
B01 - Arms/Shoulder/Elbow
B02 - Chest/Abdomen/Pelvis
B03 - Eyes
B04 - Face
B05 - Feet/Toes
B06 - Fingers/Hands/Wrists
B07 - Head/Forehead
B08 - Legs/Knees/Ankles
B09 - Multiple Areas
B10 - Neck
B11 - No Information
B12 - Spine/Back
B13 - Teeth/Mouth
B14 - Other - (please explain)
Nature of Injury - Other
Body Area - Other
Cause of Injury or Damage
C01 - Assault-No Weapon
C02 - Assault with Weapon
C03 - Choking/Suffocation
C04 - Drowning
C05 - Exposure to Fire/Electricity/Hot or Caustic Matter
C06 - Fall at Same Height
C07 - Fall from Different Height
C08 - Fatigue/Over Exertion
C09 - Foreign Body
C10 - Horseplay
C11 - Maintenance Activity
C12 - Motor Vehicle Accident
C13 - Poison/Allergic Reaction
C14 - School Bus Accident
C15 - Sports Injury
C16 - Struck Against Person
C17 - Struck/Crushed By/Against Object
C18 - Other - (please explain)
Activity at time of Incident
A01 - Academic Classroom
A02 - Between Classes
A03 - Extra-Curricular (i.e. Club)
A04 - Out-Of-Class Field Trip
A05 - Recess/Pre-Or Post Class/Noon Hour
A06 - Sports Event
A07 - Sports Related Class
A08 - Travel to or from Facility
A09 - Unorganized Sports
A10 - Work Placement
A11 - Maintenance Activity
A12 - Other - (please explain)
Cause of Injury - Other
Activity at Time - Other
SECTION B
Property Involved (describe property involved and extend of loss and/or damage)
Fire Department Attended
Fire Department Report Number
Police Notified
Branch/Detachment
Case Number
Date
Time
Were There Signs of Forced Entry
What?
Cause of Loss/Damage
C01 - Burglary/Forcible Entry
C02 - Collapse
C03 - Dishonesty/Infidelity
C04 - Explosion
C05 - Falling Object
C06 - Fire/Lightning
C07 - Glass Breakage
C08 - Impact By Vehicle/Aircraft
C09 - Riot
C10 - Robbery
C11 - Smoke
C12 - Theft
C13 - Transportation
C14 - Vantalism/Malicious Acts
C15 - Water Escape/Rupture/Freezing
C16 - Windstorm/Hail
C17 - Other - (please explain)
If Fire or Water damage, please add any extra comments here
Cause of Loss - Other
3 Submitter Information
Submitter Name
Submitter Title
Submitter Email
Name of Administrator
Principal Informed
Yes
Principal's Email
Confirm Changes
Valid Start Date
* leave date blank if change applies from beginning of time
Valid End Date
* leave date blank if change applies until end of time
Add attachments
No
Yes
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