Accident Report
Important: Email copy to:
Christy Giles - christy.giles@kctcs.edu
(859) 256-3323
Form FM84
03/08/2019
Date of Occurrence _________________________ Time of Occurrence _____________________________
Section A: Personal Information
Name: ________________________________ Student
Employee
Visitor EE/Student ID:
_____________
Facility/Campus:
________________________________________________
Accident Location:
Section B: Description of Injury
Apparent Nature of Injury Part of Body Injured
Abrasion Concussion Puncture Abdomen
Elbow L
R
Head
Amputation Cut Scald
Ankle L
R Eye L R
Knee L
R
Asphyxiation Dislocation Scratch Arm L R Face Leg L R
Bite Fracture Shock Back Finger
Mouth
Bruise Laceration Sprain Chest
Foot L
R
Other
Burn Poisoning Other Ear L R
Hand L R
If Other, explain:
If Other, explain:
Describe the nature of the injury (cut, third finger, left hand, etc.):
Describe medical attention provided or received and by whom:
Section C: Description of Accident
Did accident occur while in an instructional or work activity?
Yes No
If no, continue to Section D.
Please specify any machine, equipment, or tools involved:
If applicable, were proper machine guards used?
Yes No
Was individual using Safety Equipment?
Yes No
Describe Safety Equipment: __________________________
If Safety Equipment was not in use, explain: ________________________________________________________________________
Was individual given safety orientation?
Yes No
Was this accident/injury due to faulty equipment?
Yes
No
Did person have permission to use equipment? Yes No If no, explain: __________________________________________
Was supervisor/instructor present at accident?
Yes No
If no, explain: __________________________________________
Describe any action taken to prevent recurrence: ____________________________________________________________________
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If employee was injured, were they hospitalized for treatment?
Yes
No
If yes, was OSHA notified?
Yes
No
