Injury/Illness/Incident Report Form
ForwardcompletedformtoHumanResourcesASAP,BarlowHall204orHR@Clackamas.edu
Rev.4/2017
Instructions: CCC students, employees, and visitors shall use this form to report all injuries, illnesses, or
“near miss” events (which could have caused an injury or illness) on campus—no matter how minor.
If you are and employee and will be seeking medical treatment, you MUST complete an injured worker packet as soon as
possible. Contact Human Resources or your Supervisor for additional information.
NameofInjuredPerson:
PrimaryPhone(Personal): WorkPhone:
DateofInjury: TimeofInjury:
☐am☐pm
SpecificLocationofInjury
(i.e. building name, room number)
Campus:
☐OregonCity☐Harmony
☐Wilsonville☐Other
TransportedforMedicalTreatment?
☐Yes☐No
ByWhom?
Was911Called?
☐Yes☐No
For liability reasons, CCC staff CANNOT transport an injured or ill person.
Pleasedescribe,indetail,whathappened
(attachanothersheetifnecessary)
:
Pleaseindicatewhereyouareinjured
Pleasecheckallbodypartsthatapplyandmarkondiagram
☐
Head/Neck
☐
Right
☐
Left
☐
Shoulder
☐
Right
☐
Left
☐
Arm
☐
Right
☐
Left
☐
Elbow
☐
Right
☐
Left
☐
Forearm
☐
Right
☐
Left
☐
Wrist/Hand
☐
Right
☐
Left
☐
Abdomen
☐
Right
☐
Left
☐
Chest
☐
Right
☐
Left
☐
Back
☐
Upper
☐
Lower
☐
Hips
☐
Righ
t
☐
Left
☐
Thigh
☐
Right
☐
Left
☐
LowerLeg
☐
Righ
t
☐
Left
☐
Knee
☐
Right
☐
Left
☐
Ankle/Foot
☐
Right
☐
Left
☐
Other(
describe)
WitnessInformation:
PrintedName PhoneNumber
PrintedName PhoneNumber
InjuredPersonSignatureDate
☐Checkifinjuredpersonisunabletosign.
