Fillable Accident-report-2-2013 (Other Than Motor Vehicle)

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Accident-report-2-2013 (Other Than Motor Vehicle)

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Student/Visitor/Vendor Accident Report
ACCIDENT REPORT
Do Not Use For Motor Vehicle Accidents
STUDENT VISITOR VENDOR
TO PROTECT THE STATE OF CALIFORNIA, THE UNIVERSITY AND ITS EMPLOYEES, the following information should
be provided by the instructor, supervisor or other state employee having knowledge of an accident when a student,
visitor or vendor is injured on state property or during a state sponsored activity and/or if personal property damage is
incurred. All injuries, other than first aid, should be reported. Please report immediately if a death or serious injury
occurs. If more space is needed, please provide attachments.
Please sign and date the report in Section 4 below.
ORIGINAL:
Risk Management
COPY: Your Dept. File
Section 1
INJURED PARTY
Full Name of Injured Party: (Please Print First and Last Name)
Date and Hour of Accident:
Home Address: (Street, City, State, Zip)
Home Telephone:
Business Name of Injured Vendor:
Business Phone:
Location of Accident: (i.e. Campus Location, Class Number)
Cell/Alt. Telephone:
Nature of Injury: (specific body part and injury)
Where treated:
Description of Accident:
Assistance Rendered:
Does injured party have
medical insurance?
Yes No
Section 2
PROPERTY DAMAGE
Name of Property Owner: (Please Print First and Last Name)
Date and Hour of Loss:
Address: (Street, City, State)
Home Phone:
Nature and Extent of Damages:
Cell/Alt. Telephone:
Location of Property When Damaged:
How Property Damage Occurred:
Section 3
WITNESSES
Name of Witnesses: (Pease Print First and Last Name)
1.
2.
3.
Section 4
PERSON
COMPLETING
REPORT
Name of Person Completing this Report: (Please Print First and Last Name)
Work Phone:
Title or Work Location:
Cell/Alt. Phone:
Signature:
Date of Report:
This is a CONFIDENTIAL report to provide information for use by legal counsel in the event a claim is filed against the
State or its employees. Under no circumstances should information be given to anyone except law enforcement
officers, State officials, or persons authorized by the State.
Rev 2/2013
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Accident-report-2-2013 (Other Than Motor Vehicle)

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Completed 14 March 2020

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