FAIRMONT STATE UNIVERSITY/PIERPONT COMMUNITY & TECHNICAL COLLEGE
STUDENT/VISITOR INJURY & ILLNESS FORM
This form should be completed by the student, supervising adult or visitor following all accidents, or incidents that occur within
the schools jurisdiction or purview that:
1. Results in the injury of a student, or visitor.
2. Results in property damage.
3. Involves a student at a practicum or on any trip directly related to the students program at the institution.
a. Students on internships are under the employment of a company and are subject to that company’s injury
reporting procedures.
Please complete the following form with as much detail as possible. Attach additional pages as necessary, including reports from
witnesses. When completed please forward the form to Facility Safety located in the Physical Plant office 103, Fax 304-367-
4656, within 24 hours. Please retain a copy for your records.
Date of accident/incident: (MM/DD/YYYY)
Time of accident/incident:
AM
PM
Accident/Injury location: (e.g. building, floor and room)
Body Part(s) Injured (Check ALL that apply AND
circle the areas on the body diagram provided):
☐ Arm ☐ Head
☐ Abdomen ☐ Hip
☐ Ankles ☐ Internal
☐ Back ☐ Knees
☐ Chest Ribs ☐ Legs
☐ Ears ☐ Mouth/ Teeth
☐ Elbow ☐ Neck/ Throat
☐ Eyes ☐ Nose
☐ Face ☐ Pelvis
☐ Feet ☐ Shoulder
☐ Fingers ☐ Skin
☐ Full Body ☐ Toes
☐ Groin ☐ Wrist
☐ Hand
☐ Other ____________________________
Type of Injury (Check all that apply)
☐ Abrasion ☐ Death
☐ Amputation ☐ Dislocation
☐ Burn ☐ Fracture
☐ Chemical reaction ☐ Puncture
☐ Crush ☐ Shock/electrocution
☐ Cut/ Laceration ☐ Sprain/ Strain
http://www.docstoc.com/docs/23694266/Regional-Community-Services-Incident-Report
