DB-A2-4

Report Received by __________________________________________________ Date _________________________________

Accident Report Form

Use this form to report accidents, injuries, medical situations, or student behavior incidents. (Incidents involving a crime or traffic incident should be reported directly to the Campus Public Safety office.) If possible, the report should be completed within 24 hours of the event. Submit completed forms to the President’s Office.

INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT

Full Name

Home Address

� Student � Employee � Visitor � Vendor Phone Numbers Home Cell Work

INFORMATION ABOUT THE INCIDENT Date of Incident Time Police Notified  Yes  No

Location of Incident

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible (attached additional sheets if necessary)

Were there any witnesses to the incident?  Yes  No If yes, attach separate sheet with names, addresses, and phone numbers. Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other information known about the resulting injury(ies).

Was medical treatment provided?  Yes  No  Refused If yes, where was treatment provided:  on site  Urgent Care  Emergency Room  Other

REPORTER INFORMATION

Individual Submitting Report (print name)

Signature

Date Report Completed

FOR OFFICE USE ONLY

FOR OFFICE USE ONLY

Document any follow-up action taken after receipt of the incident report.

Date Action Taken By Whom