Fillable Idaho State University - Accident Report Form

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Idaho State University - Accident Report Form

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ACCIDENT REPORT
Date of Report: ___________________
Name of injured person: ___________________________________________
Injured person’s address: ______________________________________________________
Injured person’s phone: ________________________________________________
Injured person’s student or SS #: ____________________________________
CONDITIONS SURROUNDING THE ACCIDENT
Date: _______________________
Lab or Class: _________________ Room #: __________ Time: _________________
Supervisor: Jessica Fultz Supervisor’s Office #: LS 208
Nature of Accident (in your own words):
What was the response to the accident? What first aid was administered?
Follow up:
Name of person filing report: ____________________________ Title: ________________
Signature: __________________________________
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Idaho State University - Accident Report Form

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Completed 30 May 2020

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