SOUTHERN WEST VIRGINIA COMMUNITY AND TECHNICAL COLLEGE
BOARD OF GOVERNORS
SCP-1375.A
Accident/Incident Report Form
Date Time Day of Week
Location:
Accident/Incident:
Information on affected person:
Name
Address
City Zip Code
Date of Birth
Title
State
FOR EMPLOYEES ONLY
Time Employee Began Work
AM PM
Hire Date
Phone Number
Male Female
Accident
Incident
Murder
Burglary
Aggravated Assault
Hate Crime
Negligent Manslaughter
Vehicle Theft
Robbery
Injury
Sexual Offense ---
Drug Law ---
Liquor Law ---
Weapons ---
Forcible Non-forcible
Arrest Referral
ReferralArrest
ReferralArrest
Event type:
Treatment Information:
Yes No
Was first aid provide?
If yes, by whom?
Yes No
Was individual treated in an
emergency room?
Yes No
Was individual hospitalized
overnight as an in-patient?
Name and address of treatment facility if applicable:
Facility City
Name of Physician
What was the individual doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the individual was using. Be specific.
Information concerning the case
Examples: "Walking down stairs carrying books"; "Climbing a ladder while carrying roofing materials”; “daily computer key-entry.”
What happened?
Tell us how the injury occurred. Example: "Tripped at the bottom step when the ladder slipped on wet floor, individual fell 20 feet”; “Individual was
sprayed with chlorine when gasket broke during replacement”; For employees, “Worker developed soreness in wrist over time.”
“strained back”; “chemical burn, hand”; “carpal tunnel syndrome."
What was the injury or illness? Tell us the part of the body that was affected and how it was affected; be more specific than “hurt,” “pain,” or sore.” Examples:
What object or substance directly harmed the individual? “concrete floor”; “chlorine”; “radial arm saw.” If this question does not apply, leave blank.Examples:
If the individual died, when did death occur? Date:
Attention: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while the information is being used for occupational safety
and health purposes.
See CCR Title 8 14300.29(b)(6)-(10)
State
Employee Student Visitor Other
Number of Days Off Work
AM PM
