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1of2



FloridaCollegeSystemRiskManagementConsortium

ACCIDENT–INCIDENTREPORT

(AcopyofthisreportisNOTauthorizationformedicaltreatment)

INSTRUCTIONS:

 Ifloss/occurrence/injuryistoacollegeemployee,pleasecompletesections:1,2,5,6,7and8.

 Ifloss/occurrenceistocollege‐ownedpropertypleasecompletesections:1,3,5,6,7and8.

 Ifloss/occurrence/injuryistoanoncollegeemployeeornoncollege‐ownedproperty,pleasecompletesections:1,4,5,6,7and8.

1.LOCATIONANDDATEOFINCIDENT/OCCURRENCE

COLLEGE:(CheckOne)

 BC 

 CC

 CCF

 DSC

 EFSC

 FGC

 FKCC

 FSWSC

 GCSC

 HCC

 IRSC

 LSSC 

 MDC

 NFCC

 NWFSC

 PBSC

 PHSC 

 PeSC

 PoSC

 SFC

 SJRSC

 SPC

 SSC

 SFSC

 SCFMS



TCC

 VC

CAMPUS/LOCAT

IONCODE:



DATEOFOCCURRENCE:



TIMEOFOCCURRENCE:

AMPM

LOCATIONOFOCCURRENCE(BESPECIFIC):



2.INJUREDEMPLOYEE(INJURY/LOSSTOCOLLEGEEMPLOYEE)

NAMEOFEMPLOYEE:



AGE:



OCCUPATION&DEPARTMENT:



EMPLOYEE#:



ADDRESS:



CITY:



ST:



ZIP:



PHONE:

()

PARTOFBODYINJURED:



TYPEOFINJURY(CUT,STING,BUMP,BRUISEETC.):



DOESEMPLOYEEWISHTOSEEKMEDICAL

ATTENTIONTODAY:

YESNO*

WILLEMPLOYEEREQUIRETIMEOFF

FROMWORK:

YESNO

DATEINJURYFIRSTREPORTED:



TIMEINJURYFIRSTREPORTED:



*A“no”answerdoesnotwaivetheemployee’srighttorequestmedicalattentionatalaterdate.



3.PROPERTY(COLLEGEOWNED)

IDENTIFYTHEDAMAGED/LOSTPROPERTY:



ESTIMATEDCOSTOFDAMAGED/LOSTPROPERTY:

$



4.INJUREDPARTY/PROPERTY(PERSONSNOTEMPLOYEDBYCOLLEGEAND/ORPROPERTYNOTOWNED BYCOLLEGE) 

NAME:



AGE:



PHONE:

()

ADDRESS:



CITY:



ST:



ZIP:



IDENTIFYTHEINJURYORTHEDAMAGED/LOSTPROPERTY:



STUDENTID#

(IfInjuredPartyisAdmittedStudent):



5.WITNESS(ES)

NAME:



PHONE:

()

ADDRESS:



CITY:



ST:



ZIP:



NAME:



PHONE:

()

ADDRESS:



CITY:



ST:



ZIP:



Revised: 08/17

2of2



6.DESCRIBETHELOSS/OCCURRENCE/INJURY(TobecompletedbyInjuredEmployee/Party,ifatallpossible):



7.SIGNATURES

INJUREDEMPLOYEE/PARTY’SSIGNATURE:DATE:



DEPARTMENTCONTACT’SSIGNATURE:DATE:



8.RISKMANAGEMENTCOORDINATORREVIEW(TobecompletedbytheCollege’sRiskManagementCoordinator):

TYPEOFCLAIM(PleaseCheckOne):

 GENERALLIABILITY

 COLLEGEPROPERTYDAMAGE/THEFT

 EQUIPMENTBREAKDOWN

 WORKER’SCOMPENSATION**

 STUDENTACCIDENT 

 ATHLETIC

 FACILITIESUSE

 ALLIEDHEALTH(PleaseAttachAlliedHealthIncidentForm)

**PleasedonotsendWorkCompA/IformstotheConsortium.TheCollegeWCcoordinatorshouldsubmitallWCclaimsthroughthecallcenter.

RISKMANAGEMENTREVIEWSTATEMENTS(InitialONLYthosestatementsthatapply):



_____THISA/IISFYIONLY.NOCLAIMISBEINGSUBMITTEDATTHISTIME.

_____THISA/IHASBEENSUBMITTEDTOA-G ADMINISTRATORS,FORCLAIMREVIEW(StudentAccidentCoverage).

_____THISA/IHASBEENSUBMITTEDTOSUMMITAMERICA,FORCLAIMREVIEW(AthleticCoverage).

RISKMANAGEMENTCOORDINATOR’SSIGNATURE:DATE:





Revised: 08/17

1of2



ACCIDENT–INCIDENTREPORTINSTRUCTIONS

ThisformisusedtonotifytheFlorida CollegeSystemRiskManagementCons ortium(FCSRMC)of

accidents/incidents/occurrencesforreviewaspossibleclaims.Thisformshouldbeusedtodocumentthefollowing

typesofoccurrences:Accidents,Injuries,Crimes/Theft,PropertyDamage(CollegeOwned),PropertyDamage(Non‐

CollegeOwned),InternetCrisis(stolen,lost,orhackedperson

alinformation),EquipmentBreakdown(fkaBoilerand

Machinery),St

udentAccidents,AthleticInjuries,andAlliedHealth(ProfessionalLiabilityClaims).Pleasenote,Worker’s

CompensationclaimsarenotreportedtotheFCSRMCusingthisform.TheCollege’sWorker’sCompensation

Coordinatorshouldsubmitallclaimsviathededicatedreportingline:877‐842‐6843.

1.LOCATIONANDDATEOFINCIDENT/OCCURRENCE

COLLEGE:ClearlychecktheFCSRMCabbreviationforyourcollege.

CAMPUS/LOCATIONCODE:PleaseusethecampuscodesasnotedontheCollege’sPropertyListingsonfilewiththe

FCSRMC.

LOCATIONOFOCCURRENCE(BESPECIFIC):Providecampusnameandbuildingnameornumber.Ifaccidentoccurredoff

campus,providestreetaddressandcity.

2.INJUREDEMPLOYEE

OCCUPATION&DEPARTMENT: Listtheoccupationanddepartmentinwhichtheemployeeisprimarilyemployed.

PARTOFBODYINJURED:LooselyidentifythepartoftheEmployee’sbodywhichhas beeninjured(i.e.wrist,ankle,back

etc.)

TYPEOFINJURY:LooselyidentifythemannerinwhichtheEmployeehasbeeninjured(i.e.cut,sting,bruiseetc.)

DATEINJURYFIRSTREPORT

ED:Iftheinjurywasoriginallyreportedonadatedifferentfromthedateofcompletingthe

A/I,pleaselisttheoriginaldatetheinjurywasreported.

3.PROPERTY(COLLEGEOWNED)

IDENTIFYTHEDAMAGED/LOSTPROPERTY:Describethedamagedorstolencollege‐ownedproperty.Enterinformation

suchas:“Flooddamageto1

floorofBuildingK;or1998whiteMercedesdriversidedoor;orGlassbrokeninclassroom

window;orIBMPentiumIIcomputer,monitor,keyboard,andHewlett‐PackardLaserJetprinter.”

ESTIMATEDCOSTOFDAMAGED/LOSTPROPERTY:Enteryourbestguessofthevalue.Thisfigurewill not beusedin

evaluatingtheclaim.Itwillbeanindica

tionofwhetherornotitfallswithinthecollegedeductibleandwhetherornotit

needstobesubmitte

dtotheservicingoffice.

4.INJUREDPARTY/PROPERTY(INJURY/LOSSTOPERSONSNOTEMPLOYEEDBYCOLLEGEAND/ORPROPERTYNOTOWNEDBYCOLLEGE)

NAME:Reportthenameoftheimpactedperson,suchas,studentswhoarenotemployeesofthecollegeatthetimeof

injury,visitors,orownersofpropertythatisstolenordamagedwhileatthecollege,includingartexhibits.

IDENTIFYTHEINJURYORTHEDAMAGED/LOSTPROPERTY:Enterinformationsuchas“Twistedknee;or1989white

Mercedesconvertible;orbluebackpackwith4textbooks;orWalkmanradio/tapeplayer;etc.”



Revised: 08/17

2of2



5.WITNESS(ES)

Thisinformationisextremelyvaluableinadjustingtheclaimsorifsuitsarefiledlater.Pleasesupplytheinformationifit

isavailable.

6.DESCRIBETHELOSS/OCCURRENCE/INJURY(Tobecompletedbytheinjuredperson,ifatallpossible):

Pleasedonotwrite“SEEATTACHED.”Pleasegiveabriefdescriptionofaccidentusingwordssuchas:“College‐owned

vehiclewashitbyvehicleownedbystudent;orEmployeetrippedoverphonecord;orStudentleftbackpackonlibrary

stepsfor10minutes;orVehicle1(student‐owned)hitvehicle2(stude

nt‐owned)whilebackingoutofparking

space.”

Ifadditionalspaceisrequired,feelfreetoattachasecondA/Iform.

Itisextremelyimportanttorememberthatthoseofusreadingtheaccident/incidentreportsaftertheyhaveleftyour

collegehavenoideawhotheinvolvedpeopleare,whethertheyarecollegeemployees,studentsorvisitors,andwe

havesomedifficultydeterm

iningwhetherornotdamagedpropertyiscollegeownedornon‐collegeowned.

7.SIGNATURES

Wherepossible,pleasegetthesignatureoftheInjuredEmployee/PartyandaDepartmentContact.

8.RISKMANAGEMENTCOORDINATORREVIEW(Tobe completedbytheCollege’sRiskManagementCoordinator):

ReviewbytheRiskManagementCoordinatororhis/herdesigneeareextremelyimportant.Ourbeliefiseveryincident

shouldbesubmittedthroughtheCoordinator’sofficeforreviewandthatofficeshouldacceptresponsibilityfor

submittingthereporttotheConsortiumoffice.Itisimportantforlosscontrolpurposestohaveonepersonatthe

collegecoord

inatingincidentinformationandtaki

ngresponsibilitytomakesureareasinneedofrepairarereportedto

theproperpeopleforthistobeaccomplished.

GENERALLIABILITY:Checkthisblockwhenincidentinvolvesstudents,visitors,propertyofstudentsorvisitors.

COLLEGEPROPERTY:Checkthisblockwhenincidentinvolvespro

pertyownedbythecollege.

EQUIPMENTBREAKDOWN:Checkthisblockonlywhenin

cidentinvolvesyourcollegeownedboilerand/orrefrigeration

equipment.

STUDENTACCIDENT:Checkthisblockiftheinjuredpartyisenrolledinacoveredcurriculum.

ATHLETIC:Checkifclaimantwasparticipatinginanenrolledsport.

FACILITIESUSE:Checkthisblockwhenincidentinvolvesvisitorstoaneventfor

whichFacilitiesUsecoveragehasbeen

purchased.

ALLIEDHEALTH:CheckthisblockwhenincidentinvolvespatientsofstudentsenrolledintheAlliedHealthProgram.Be

suretoattachanAlliedHealthIncidentFormfoundathttp://fcsrmc.com/attachments/Allied_Heath_Incident_Form.pdf

RISKMANAGEMENTREVIEWSTATEMENTS:InitialtheappropriatestatementstolettheFCSRMCstaffknowthatthe

RiskManagementCoordinatorhasreviewedtheclaimanddeterminedthattheA/IisforFYIpurposesonly,isaStudent

AccidentclaimthathasbeenforwardedtoFringeBenefits,ORisanAthleticclaimwhichhasbeensubmittedtoSummit

America.Byinitialingtheappropriate

statements,wehopetomakethenotificationprocessmoreefficientandlimitthe

numberoffollow‐upcallstheFCSRMChastomaketotheCollegeRiskCoordinator.

Revised: 08/17

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