Forms Manager

Student Accident Report Form

Full Name of Student

Academic Department

Full Name of Supervisor

Supervisor Phone Number (campus)

Building

This form should be filled out by the injured student and the supervisor.

Date:

Time accident occurred (indicate a.m. or p.m.)

Room or area in which accident occurred

Course attending when accident occurred

Nature of Injury

Check all that apply.

Abrasion

Amputation

Asphyxiation

Bite

Bruise

Burn

Chemical contact

Concussion

Cut

Dislocation

Fracture

Laceration

Poisoning

Puncture

Repetitive Stress Injury

Scratch

Shock

Sprain

Splinter

Strain

Other (if other please indicate below)

Other (please specify)

Part of Body Injured

Check all that Apply

Abdomen

Ankle

Back

Chest

Ear

Elbow

Eye

Face

Finger

Foot

Forearm

Hand

Head

Knee

Leg

Mouth

Nose

Shoulder

Teeth

Wrist

Other (if other please indicate below)

Other (please specify)

Description of Accident

How did the accident happen? What was the student doing?

List environmental conditions that may have contributed to the accident (i.e. distracted, heat, noise, light, etc.)

Tool/Machinery/Instrument Involved

The following questions should be answered by the accident victim.

Did the accident occur during class time?

	Yes
	No

Did the accident occur in the recommended work area?

	Yes
	No

Have you been given information concerning the safe use of the equipment/processes involved?

	Yes
	No

Have you been given a demonstration concerning the safe use of the equipment/processes involved?

	Yes
	No

Check PPE(s) worn at the time of the incident

Gloves

Goggles

Face shield

Other (if other please indicate below)

Other (please specify)

Did you apply or receive first aid?

	Yes
	No

Who gave the first aid treatment?

Did your Instructor/TA recommend that you go to the clinic/health cente

Yes No

Did you contact Security or Life Safety?

Yes No

Did you go to the clinic/health center for treatment?

	Yes
	No

What recommendations do you have for preventing other accidents of this type?