LUZERNE COUNTY COMMUNITY COLLEGE
Public Safety Training Institute
Nanticoke, PA 18634
STUDENT ACCIDENT REPORT
IF ACCIDENT OR ILLNESS REQUIRES HOSPITAL TREATMENT OR RESULTS IN A FATALITY THE
PUBLIC SAFETY TRAINING INSTITUTE DIRECTOR& SECURITY SHOULD BE CONTACTED
IMMEDIATELY AT (570) 740-0481 OR EXT. 7481, (570) 436-0577/ SECURITY AT EXT. 7304
Date of Accident:/Illness Time of Accident
Date Reported Time Reported
Location Accident Occurred County
Name Social Security No.
Address Date of Birth
Sex
Organization _____________________________ Chief ____________________ Phone No. ______________________
Nature of Injury/Illness ______________________________________________________________________________
______________________________________________________________________________
Care Provided: ! None Required ! First Aid on Scene ! Treatment by Physician ! Refused Treatment
! Transported to Medical Facility Name of Medical Facility _________________________
Unit Transporting to Medical Facility ____________________________ ! BLS ! ALS
Severity: ! Fatality ! Disabling ! Non-disabling ! Unknown (follow up required)
Cause: !Burns !Fall !Struck by Object !Lifting !Sharp Object !Apparatus ! Equipment
!Other (Explain): __________________________________________________________________
Unsafe Condition: !Yes !No Unsafe Act: !Yes !No
Explain: ___________________________________________________________________________
! Illness (Explain): ________________________________________________________________________
Brief Description of Accident: _________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Recommendation for Prevention of Recurrence: ___________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Student’s Signature Date Instructor’s Signature Date
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