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Home
» Student Accident/Injury Report
Student Accident/Injury Report
If you see this don't fill out this input box.
This form is not to be completed by the student.
*
Date
*
Date and Time of Injury
Student Accident/Injury Report Taken By
*
Student Information
Student Name
*
Date of Birth
Student ID
Address
City
State
Zip Code
Student Cell Phone Number
Student Home Number
Student Email Address
Name of Student’s Health Insurance Plan (If Available)
Emergency Contact Name
Emergency Contact Phone
Accident Injury Summary
Location where accident occurred
Was first aid rendered to student?
Yes
No
Denied Treatment
If first aid was rendered to student, by whom?
Which body part(s) were injured
Was the student participating in a college class or sponsored event?
Yes
No
Was the student transported to the hospital?
Yes
No
If the student was transported to the hospital, how?
How did the accident occur? (Include equipment used, tasks undertaken, etc.)
What can be done to prevent future similar injuries?
Disposition of Student (back to class, recovering at home, hospital)
Police Report Taken?
Yes
No
Witness Information
Witness Name
Witness Phone
Signature of Person Completing Form
*
Submit
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