Fillable Cuesta College Nursing and allied health Incident Report

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Cuesta College Nursing and allied health Incident Report

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Nursing and Allied Health, March 2017
P.O. Box 8106
San Luis Obispo, CA 93403
Nursing and Allied Health Division
Highway 1, Bldg. 2300, Office 2315
San Luis Obispo, CA 93045
Phone (805) 546-3119
Fax (805) 546-3961
Incident Report
PART 1: Instructor Statement
STUDENT NAME:
DATE & TIME OF INCIDENT/INJURY:
LOCATION WHERE INCIDENT OCCURRED:
COURSE TITLE AND INSTRUCTOR NAME:
DESCRIPTION OF INCIDENT:
Student has declined medical treatment for the above injury/incident: ________ (instructor’s initials)
Completed and signed by:
Date:
INSTRUCTOR’S RESPONSIBILITY:
1.
For SERIOUS OR EMERGENCY injuries/incidents in the classroom, skills lab or clinical setting send student to
Hospital ER or CALL 911.
• If injury/incident occurs in a clinical or healthcare agency and the student is treated in the Hospital ER, notify
the Infection Control/Employee Health Nurse.
2.
For MINOR injuries/ incidents in the classroom, skills lab or clinical setting offer the student treatment, and if desired, send
him/her to an Approved Urgent Care Facility*
3.
For ALL injuries/incidents:
• Immediately notify the Director of Nursing or the Director of Allied Health of the incident.
Office Phone: 805-546-3119. Leave a message if after hours.
• Complete Part 1, Instructor Statement, of the Incident Report. Give Part 2, Student Statement, to the student
to complete and return to you, even if treatment is declined.
• Submit Part 1 and Part 2 to the Cuesta Nursing/Allied Health Office (Fax: 805-546-3961). The office will then
notify Human Resources.
4.
If student receives medical treatment for any injury or incident that occurred in a classroom, skills lab or clinical
setting, the student is required to go to the Cuesta College Human Resources Office to complete required Workers’
Compensation claim forms. These forms MUST be completed and submitted to the Human Resources Office within
24 hours of the incident or on the College’s next regularly scheduled workday.
*Approved Urgent Care Facilities:
Paso Robles: MedPost Urgent Care, 500 1
st
St/Vine, Paso Robles, CA Phone: (805) 226-4222
Pismo Beach: Med Plus, 877 Oak Park Blvd., Pismo Beach, CA Phone: (805) 474-8450
San Luis Obispo: Med Stop, 283 Madonna Rd, Suite B, SLO, CA Phone: (805) 549-8880
Nursing and Allied Health, March 2017
P.O. Box 8106
San Luis Obispo, CA 93403
Nursing and Allied Health Division
Highway 1, Bldg. 2300
San Luis Obispo, CA 93045
Phone (805) 546-3119
Fax (805) 546-3961
Incident Report
PART 2: Student Statement
STUDENT NAME:
STUDENT BANNER ID NUMBER:
STUDENT MAILING ADDRESS:
STUDENT PHONE NUMBERS (CELL & HOME):
DATE & TIME OF INCIDENT/INJURY:
LOCATION WHERE INCIDENT OCCURRED:
COURSE TITLE AND INSTRUCTOR NAME:
DESCRIPTION OF INCIDENT:
I decline medical treatment for the above injury/incident: ________ (student’s initials)
If declining medical treatment, state reason:
Completed & signed by:
Date:
STUDENT’S RESPONSIBILITY:
For Office Use Only
1.
For ALL injuries/ incidents: IMMEDIATELY report injury/incident to Cuesta Instructor.
Program:
2.
Complete Part 2, Student Statement, of the Incident Report and submit it to your Cuesta
Instructor. Instructor will submit this form to the Nursing and Allied Health office.
Start Date:
If student receives medical treatment for any injury or incident that occurred in the
classroom, skills lab or clinical setting during class hours, the student is required to go
to the Cuesta College Human Resources Office to complete required Workers’
Compensation claim forms. These forms MUST be completed and submitted to the
Human Resources Office within 24 hours of the incident or on the College’s next
regularly scheduled workday.
Treatment
Received?
Yes
No
Follow-up
Required?
Yes
No
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Cuesta College Nursing and allied health Incident Report

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Completed 26 December 2019

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