INJURED PERSON [fills out this section]
___________________________________________________________ __________________________ ___________________
Last Name First Middle SSN (last 4 digits) Today’s Date
_________________________________________________________ ______________________________________________
Street City State Zip
Phone # (______)_______________________ Birth Date:__________________ Employee’s Email: ________________________________
Check One: Student Short Term Employee Public Child Care
Position/Title: ________________________ Hire / Start Date: ___________________ Hourly Rate: _____________________
Average Hours Worked/Daily: __________ Average Days Worked/Week __________ Average Total Hours Worked/Week ___________
Location of Incident:
WV___ MC___ Other___ Building/Room ______________________
(Other location, please describe or attach maps)
Date of Incident: __________________ Time: _______________ Time Employee Started Work on Incident Date: _________________
For accidents in class or lab activities:
____________________________________________________ _________________________________________________
Instructor Name Course name
____________________________________________________ _________________________________________________
Other Witness/es Name(s) Phone No.
Injured Party: Please describe how accident/injury/incident occurred, and be specific:
______________________________________________________________________________________
______________________________________________________________________________________
_____________________________________ ____________________________________ ______________________
Print name of Injured Person Signature of Injured Person Date
COLLEGE PERSONNEL [only college personnel may fill out the following information]
Describe part of body affected, condition/ injuries (do not diagnose) __________________________________
___________________________________________________________________________
First Aid/ Treatment given ___________________________________________________________
___________________________________________________________________________
Referred to (check one): Emergency Facility MD Home Worker’s Comp Clinic Other__________________________
Follow-up plans (if applicable) _________________________________________________________
Insurance (check one): Student Accident Insurance Worker’s Comp. Kaiser Medi-Cal Other __________
Was Accident Insurance information given to student: Yes No (If insurance needed, contact Student Health Services)
Did injured person’s blood or body fluid come in contact with student or staff? Yes No
If yes who _______________________________________________________ ______________ Phone # _____-______________
(Print Name) (Last 4 digits)
Did injured person’s blood or body fluid come in contact with any surface or equipment? Yes No
If yes, who decontaminated area, and how? _________________________________________________________
Employee accidents/ blood exposure must be reported immediately to: HR @ 408 741-2128 and FAX INCIDENT REPORT to #: 408-867-9059
_______________________________________ ________________________________ _________________
Signature of College Personnel filling out form Department Date
Send completed form to Human Resources WVMCCD Accident/Injury/Incident Report 11/2014 hr
EST
ALLEY
ISSION
OMMUNITY
OLLEGE
ISTRICT
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