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INCIDENT REPORT BUTTE-GLENN COMMUNITY COLLEGE DISTRICT 3536 Butte (Butte College)

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BUTTE-GLENN COMMUNITY COLLEGE DISTRICT
3536 Butte Campus Drive, Oroville, CA 95965
INCIDENT REPORT
BGCCD-INCIDENT REPORT (04/12) Risk Management
INSTRUCTIONS
The district employee who either witnesses or has knowledge of an accident should use the Incident Report form to report any non-work related accident
on district property or involving District employees that may require first-aid or medical care. THIS IS A CONFIDENTIAL – ATTORNEY/CLIENT PRIVILEGED
DOCUMENT that is to be used to provide information for use by legal counsel in the event a claim is filed against the Butte-Glenn Community College
District or its employees. Under no circumstances should this document or information in this document be shared or given to anyone with the exception
of authorized District officials. Attach photos and diagrams as appropriate. Use Report of Vehicle Accident form to report an accident involving autos. Use
Report of Accident/Injury form to report a work-related accident. Submit completed form to Student Health Clinic within 48 hours.
INJURED PARTY
Name of Injured Party:
Work Ph:
Home Ph:
BGCCD ID No:
Birth date:
Gender: Male Female Relation to BGCCD: Staff Faculty Student Visitor Other
ACCIDENT
Date:
Time of Day:
Location:
Describe class, sport or activity engaged in at time of accident:
Describe how accident occurred:
Describe action taken by staff:
ATTACHMENTS: Photo(s) Diagram(s) Staff statement(s) Witness statement(s) Other
REPORTED TO: College Police Local Police Sherriff CHP Paramedic Other
BODILY INJURY
Describe injury (if any):
How was injury caused:
If treated, where: Name of doctor: Ph:
PROPERTY DAMAGE
Property damaged (if any):
Owner (if not Injured Party):
Address:
Ph:
Describe damage:
How was damage caused:
WITNESSES
Witness:
Home Ph:
Bus. Ph:
Address:
Witness:
Home Ph:
Bus. Ph:
Address:
Witness:
Home Ph:
Bus. Ph:
Address:
REPORT BY
Name of Reporting Employee:
Dept:
Date:
Signature of Reporting Employee:
Date:
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FREQUENTLY ASKED QUESTIONS
Incident Reports
BGCCD-FAQ-INCIDENT REPORT (04/12) Risk Management
STUDENT, VENDOR, VISITOR ACCIDENT (Non-auto, Non-employee)
When should this form be used?
Whenever a non-vehicular accident; an injury to a student, vendor or other campus visitor occurring on District
property or during a District sponsored activity; and/or damage to District or personal property occurs.
This report is not intended to be completed and submitted for "employee accidents" or for "motor vehicle
accidents" because other forms and procedures apply to them.
What is the Incident Report?
This form is intended to record the initial facts of an incident. Only fill out the sections that apply to your
incident/accident. Attach additional sheets as needed to describe the incident. Please do not include opinion or
speculation in the report. You are not expected to conduct an investigation of the incident. If an investigation is
warranted, it will be conducted by another agency (i.e.: police, fire department, insurance company, etc.) or
initiated by District’s Risk Management office. This form will be kept confidential and only used by District
officials or agents acting on behalf of the District. If you have any questions about this form, contact Risk
Management at (530) 895-2341.
Who should use this form?
A Butte-Glenn Community College District employee who either witnesses or has knowledge of the
accident/incident should complete an Incident Report..
What if I do not have all of the requested information?
The information provided should be as detailed as possible, especially if there are serious injuries. Photos and
diagrams can be submitted as necessary. This report supplements, but does not replace, any Campus Police
report that may be developed. If some information is not be applicable or available, please submit basic
information, and you can amend the report later if more information becomes available.
What do I do with the completed form?
Submit the completed Incident Report form to the Student Health Clinic immediately if a serious injury occurs and
within 48 hours for others.
Where do I obtain a copy of the Incident Report form?
You may obtain copies of the Incident Report form from the Risk Management office, Facilities Planning &
Management, Student Health Clinic, Athletics Department office, or on the internet at:
http://www.butte.edu/fpm/.
What is an incident?
An "incident" refers to loss/damage to college property, loss/damage to personal property, criminal activity or an
injury involving a student or visitor occurring on campus or participating in a college activity.
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INCIDENT REPORT BUTTE-GLENN COMMUNITY COLLEGE DISTRICT 3536 Butte (Butte College)

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Completed 25 July 2020

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