Copper Mountain College Incident Report Form – Employees*, Students, and Visitors
*Injured
faculty/staff
should also use Worker’s Comp Procedures and forms on College website.
D
ate and Time of
Incident
:
Date and Time of
Report
: ________________________________
Please complete this form to document any unusual occurrences or incidents on campus or a CMC off-campus sponsored event.
1. Name of Reporting Person:
_______________________________________ Phone: ________________________________
Last First Middle Initial
Position of Reporting Person: _____________________________________________
2.
Name of Involved Party: ___________________________________ Phone: _________________
Last First Middle Initial
Optional Information: Age:
____ Gender:
(
______) Ma
l
e
(_____)
Fema
l
e
Student
ID
Number
(if
applicab
l
e):
________________
3. Type of Incident:
( ___) Bodily Injury (______) Vehicle (______) Behavior (_____) Theft
Ot
her (PLEASE SPECIFY):_________________________________________________________________________
4. Status o
f Involved Party at time of accident:
(_____)
Student (_____) Visitor (_____) Faculty/Staff (_____) Student Athlete
5. Specific
l
ocation
of
incident:
Building
and
Room
Number:
_________________________
6. If incident occurred at an off-campus location, was the activity College-sponsored? _____Yes
______
No
** If “YES” please provide address of location: ____________________________________________________________________
7. Describe incident (include device, machine, material, Safety Data Sheet (SDS), or condition involved, activity engaged in at the
time of incident, and type of injury and part of body involved: **Please attach additional witness statement if necessary**
__
_____________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
8
.
The individual named in this report (_____) DID (____) DID NOT or (_____
) N/A refuse assistance, such as treatment on
the scene, transportation for medical treatment, etc.
_______________________________________ _______________ ______________________________
**If Medical Treatment Refused Signature of Injured Party Required Date
Police or Sheriff Notified? (_____) YES ** if YES, File Number: ______________________ or (_____) NO
If Photos of incident are available please email copies for documentation to distribution list “Security Office”
9.
Please list the College official who was first notified of this incident and the date of that notification.
College Official (Print Name) College Official (Signature) Date of Notification
Signature of Individual Making the Report Date of Report
Signature of Security Officer Date Report Received
COMPLETED FORM SHOULD BE EMAILED TO THE SECURITY OFFICE VIA THE
DISTRIBUTION LIST LABELED “SECURITY Office”
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signature
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