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

Fill Online, Printable, Fillable, Blank Accident-report-rev-2-2013 (Other Than Motor Vehicle) Form

Use Fill to complete blank online CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 9 minutes to complete

The Accident-report-rev-2-2013 (Other Than Motor Vehicle) form is 1 page long and contains:

  • 0 signatures
  • 5 check-boxes
  • 32 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California State University Channel Islands

BROWSE CALIFORNIA STATE UNIVERSITY CHANNEL ISLANDS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 14 March 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document