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INSTRUCTIONS:
Report your accident/Injury to your Dept. Chair within 8 (eight) hours. Copies of the Accident/Injury Report should be distributed to Dept. office and Risk Management (SA RM4700) within 24 hours of date of Accident/Injury.
Note: If you are a student employee do not complete this form. Complete the Workers Compensation Employee Injury/Illness form located on the Risk Management web site.
I. STUDENT ACCIDENT/INJURY
Name: ______________________________________________________ _____ Student ID #: ________ ______________
Home Address: ___________________________________________________________________________ _______
Number & Street City State Zip
Phone: __________________________________ Email: ____________________________________________________________
Instructors Name: ________________________________ _____ Phone:____________________________________________
(If applicable)
Date and Time of Injury / Illness: _____________________ Did injury/illness result in medical treatment? No Yes
Initial treatment location: ______________________________________________ Phone: _______________________________
Were you working as a student intern? No Yes If yes complete section II
II. STUDENT INTERN ACCIDENT/INJURY Only complete this section if you are a student intern
Course: _____________________________________________ Internship Department: ___________________________________
Supervisors Name at worksite location: _____________________________________ Phone: _______________________________
Worksite contact person? __________________________ ____ Phone:
III. FACTS RELATED TO ACCIDENT/INJURY
Location of Accident/Injury _____________________________________________________________________________________
Address & Building Room Number City
Accident/Injury reported to ________________________ Date & Time Accident Reported: __________________________________
Part(s) of the Body Injured/Affected: (ie left wrist strain): ___________________________________ ______________
Nature of Injury/illnes________________________________________________________________________________________
___________________________________________________________________________________________________________
Name of Witness: _____________________________________________ Phone: _______________________________________
Name of Witness:_____________________________________________ Phone: _______________________________________
Describe how the accident/injury occurred (If more space is needed, please attach paper) ___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
What action was taken? (i.e., contacted Dept. Office, college Office, called 911, etc.): ___________________________________ ________________________________________________ __________________________________________________
___________________________________________________________________________________________________________
Corrective action taken, if applicable:
Instructor Signature Date
(If applicable)
Students Signature Date
12/10
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