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Accidentreportform

This document is a general accident report form that is to be completed within 24 hours of any accident and routed to security. It requests personal information about the injured person such as name, address, date of birth, and insurance information. It also asks for details about the injury or illness including the date, time, location, how it happened, and what caused it. Witness information is collected as well. The form is to be completed by the supervisor or instructor and first aid details noted. Recommendations to prevent future accidents are also requested.

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Tomasz31-5
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49 views1 page

Accidentreportform

This document is a general accident report form that is to be completed within 24 hours of any accident and routed to security. It requests personal information about the injured person such as name, address, date of birth, and insurance information. It also asks for details about the injury or illness including the date, time, location, how it happened, and what caused it. Witness information is collected as well. The form is to be completed by the supervisor or instructor and first aid details noted. Recommendations to prevent future accidents are also requested.

Uploaded by

Tomasz31-5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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General Accident Report Form

COMPLETE REPORT WITHIN 24 HOURS OF ACCIDENT AND ROUTE REPORT TO SECURITY, CC-123.

Personal Information:
Name of injured person _______________________________________________________________________________________
❑ Student ❑ Employee ❑ Visitor ❑ Co-op child ❑ Work study ❑ CWE
Home address _____________________________________ Home phone _____________________________ ❑ Male ❑ Female
Date of birth ____________________ Personal health/accident insurance _______________________________________________
ID number _________________________ LBCC department _______________________________________ Ext. # ___________
Supervisor/instructor ______________________________________________________________________ Notified? ❑ Yes ❑ No

Injury/Illness Information:
Date of accident/illness _____________________________________________ Time ______________________________________
Location (building, room) ____________________________ Address (if off campus) ______________________________________
Person was in: ❑ Class ❑ Work situation* ❑ Other ___________________________________________________________
Describe injury (part of body affected) ___________________________________________________________________________
Describe how accident happened _______________________________________________________________________________
__________________________________________________________________________________________________________
Describe why injury/illness occurred and basic cause (wrong equipment, lack of training, unsafe condition, etc.) _________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Names of witnesses (include address/phone number):


__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Person filing report (print) _____________________________________________________ Phone # _______________________
Signature ______________________________________________________________________ Date _______________________

TO BE COMPLETED BY SUPERVISOR/INSTRUCTOR/SAFETY COORDINATOR

Recommendation to prevent reoccurrence; resolutions/actions taken:


__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Name of instructor or supervisor _____________________________ Signature _________________________________________

First aid administered by ___________________________________________________________________________________


Describe first aid administered, transport to medical facility by whom __________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

*Employee and workstudy on-the-job injuries/illnesses that require medical attention or involve time loss are to be recorded on a
Worker’s Compensation, OR State 801 form, available in the Human Resources Office, CC-113.
CC: Safety Coordinator _______________ Human Resources _________________ Adm. & Student Services __________________
Revised 5/20/04

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