CCTC FIRST REPORT OF INJURY/ILLNESS/EXPOSURE
Revised 10/18/17
Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
SSN:
DOB:
Gender:
Marital Status:
Role at CCTC: Employee Workstudy Student Clinical Student Student Intern
Division/Department Employed/Enrolled with:
Time your workday/class begins:
Date of incident:
Time of Incident:
Time you came to campus of day of incident:
Location of incident (i.e. Bldg#, Room #, Bldg. name, etc. ):
Specific activity engaged in when incident occurred (i.e. walking, running, climbing, standing, sitting, etc.):
Equipment/chemicals/materials used when incident occurred (i.e. motor vehicle, roll cart, mop, cleaning spray, etc.):
Type of incident (i.e. MVA, needle stick, blood spatter, cut, bruise, etc.):
Part of body affected (i.e. right thumb):
Describe the incident in detail (who, what, where, why, when and how):
What treatment was offered at scene: Yes No None Needed
If “Yes”, what type of treatment was offered? Simple first-aid Other (please list)
Was treatment accepted or refused?
Accepted Refused N/A
Do you wish to seek treatment by a physician at this time? Yes No
Was safety equipment provided: Yes No
If “Yes”, was it used? Yes No
Witness Name:
Phone Number:
Was EMS assistance offered?
Yes No
Was EMS treatment accepted or declined?
Accepted Declined N/A
Employee / Student Signature:
Date:
Name of Instructor/Administrator notified:
Date:
Instructor/Administrator Signature (if applicable):
Date:
Name of person taking report:
Date:
Signature:
Date:
HR USE ONLY
Hire Date: __________ or Date Course Began: ___________ Salary: $_____________ or Hourly Rate: $___________
Date/time reported to HR: _________________
Report to Compendium required? Yes No
If “Yes”, date/time reported: _________________
Report to Compendium made by:
______________________ Initials: _____________
Name and Address of treatment facility:
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