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CLOVIS COMMUNITY COLLEGE INVESTIGATION OF AN ACCIDENT/LOSS (Clovis Community College)

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CLOVIS COMMUNITY COLLEGE
INVESTIGATION OF AN ACCIDENT/LOSS
This form is to be completed as soon as possible after a loss has occurred. This report shall be
submitted to the Human Resource Services Office.
1. Type of Loss (circle) Injury Property Loss Damage Theft
2. Name of injured________________________________________________________
Address______________________________________________________________
SSN _________________________________ Phone No. _____________________
3. Date __________________________________Time ____________________ (am/pm)
Location _____________________________________________________________
4. Describe situation/accident/nature of injury (What happened, Who, How, Loss Resulting)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5. Instructional Program _____________________ Instructor _____________________
6. List Witnesses ________________________________________________________
_____________________________________________________________________
7. List immediate actions taken ____________________________________________
_____________________________________________________________________
8. How could problem be prevented _________________________________________
_____________________________________________________________________
9. Safety regulations observed ______________________________________________
_____________________________________________________________________
10. Person completing report _______________________________________________
Signature ____________________________________ Date ______________________
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Resource Services.
07/01/08
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CLOVIS COMMUNITY COLLEGE INVESTIGATION OF AN ACCIDENTLOSS (Clovis Community College)

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Completed 20 September 2020

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