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