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FAIRMONT STATE UNIVERSITY STUDENT/VISITOR INJURY & ILLNESS FORM (Fairmont State College)

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1
FAIRMONT STATE UNIVERSITY
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.
Please note, stu
dents on internships are under the employment of a company and are subject to that company’s injury
reporting procedures.
All injuries must be submited within 24 hours of occurance. Please complete the form with as much detail as possible. Attach
additional pages as necessary, including reports from witnesses. Please email completed form to Environmental Health & Safety
at EHS@fairmontstate.edu. Follow up with original signed form via campus mail to the Safety Manager, Facilities Department,
Room 106. Please retain a copy for your records. For questions or to report urgent accidents/injuries, please call (304) 367-4110.
Status: Student
Visitor
Date of accident/incident: (MM/DD/YYYY)
Time of accident/incident:
AM
PM
Name of Injured: (Last, First MI)
Phone Number:
Email Address:
Address:
City:
State:
Zip Code:
☐ 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 ____________________________
http://www.docstoc.com/docs/23694266/Regional-Community-Services-Incident-Report
2
Was first-aid rendered? Yes No
If yes, please list:
Have medical services been rendered to the Student/Visitor? Yes No
If yes, please list location and by who:
Person Completing Form (Print):
Name (Sign):
Responsible Person/ Supervising Adult/ Faculty/ Staff (Print):
Name (Sign):
Phone Number:
Email:
Date:
Received By (Print):
Recieved By (Sign):
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FAIRMONT STATE UNIVERSITY STUDENTVISITOR INJURY & ILLNESS FORM (Fairmont State College)

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Completed 23 July 2020

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