Fillable Form 1.: Report of Incident REQUIRED INFORMATION So (Mt. San Jacinto Community College District)

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Form 1.: Report of Incident REQUIRED INFORMATION So (Mt. San Jacinto Community College District)

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This document revised on 6/29/17 - NP
Report of Incident
Male
Student
Employee
So the District can respond effectively, please report all incidents immediately
to the person to whom you report. If you are unsure who to contact, the
Office of Instruction at any location or Risk Management are able to assist.
REQUIRED INFORMATION
Female
Other
Visitor
1.
Contact Name ____________________________________________________________________
2.
Address
Number Street City
Zip Code
3.
Cell Phone
4. Home Phone
5.
Student ID (if available)
6.
Email Address _________________________________
7.
Insurance Coverage
a.
Name of Insurance Company
b.
Insurance Address
c.
Policy Number
Group Policy
8.
Accident Time and Date
Month Day Year
Time
9.
Description of Accident, Damage or Injury:
Individual Policy
10.
Location where Accident Happened
d.
If Off-Campus, what Facility?
11.
Action taken by District Representative:
/
AM
PM
RISK MANAGEMENT
This document revised on 6/29/17 - NP
Email/Phone
Report completed by:
Date
SUPPLEMENTARY
INFORMATION IF KNOWN:
13.
Additional Contact:
14.
Action taken:
15.
Campus Safety/Sheriff/Risk Management notified by:
Action taken by emergency personnel or staff:
16.
Did individual receive medical treatment?
Yes
No
Description
17.
Was individual admitted to the hospital?
Yes
No
Name of Hospital
18.
How was Injured Party transported to Doctor, Hospital or Home:
Submit this form to Risk Management or any location's Office of Instruction:
Please email this form directly to riskmanagement@msjc.edu or mail to:
MSJC, Attn: Risk Management, 1499 N. State Street, San Jacinto, CA 92583.
Incident Report - Page 2
Name
Name Title
Date
Email/Phone
Name
12. Witnesses, if any:
Risk Management (District)
San Jacinto (SJC)
Menifee Valley (MVC)
Temecula Education Center (TEC)
San Gorgonio Pass (SGPC)
(951) 487-3135 or (951) 639-5131
(951) 487-3400
(951) 639-5400
(951) 506-6752
(951) 922-1327
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Form 1.: Report of Incident REQUIRED INFORMATION So (Mt. San Jacinto Community College District)

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Completed 5 September 2020

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