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Nah Student Injury Report Fillable

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REV 8/2019
P.O. Box 8106
San Luis Obispo, CA 93403
Nursing & Allied Health Department
Main Office: CA Highway 1, Bldg. 2700, Room 2722
San Luis Obispo, CA 93405
Phone (805) 546-3100, ext. 2798 Fax (805) 546-3961
Student Injury/Exposure Report
PART 1: Instructor Statement
STUDENT NAME:
DATE & TIME OF INJURY/EXPOSURE:
LOCATION OF OCCURRANCE:
COURSE TITLE AND INSTRUCTOR NAME:
DESCRIPTION OF INJURY/EXPOSURE:
Student has declined medical treatment for the above injury/incident: ________ (instructor’s initials)
Completed and signed by:
Date:
INSTRUCTOR’S RESPONSIBILITY:
1. For SERIOUS OR EMERGENCY injuries/incidents in the classroom, skills lab or clinical setting send student to
Hospital ER or CALL 911.
• If injury/exposure occurs in a clinical or healthcare agency and the student is treated in the Hospital ER,
notify the Infection Control/Employee Health Nurse.
2. For MINOR injury/exposure in the classroom, skills lab or clinical setting, offer the student treatment, and if desired, send
him/her to an Approved Urgent Care Facility*
3. For both Serious and Minor injuries/exposures, also do the following:
• Immediately notify the Director of Nursing or Director of Allied Health of the incident via email.
• Complete Part 1, Instructor Statement of this report. Give Part 2, Student Statement to the student to
complete and return to you,
even if treatment is declined
.
• Submit Part 1 and Part 2 to the Cuesta Nursing/Allied Health Office and Fax to: 805-546-3961). The office
will then submit the forms to Human Resources.
4. Instructor must also notify Human Resources within 24 hours of the injury/exposure either via email at hr@cuesta.edu or call
805-546-3100 ext. 3129. (HR will contact student for any required follow-up)
*Approved Urgent Care Facilities:
Paso Robles: MedPost Urgent Care - 500 1
st
St/Vine, Paso Robles, CA
Pismo Beach
: Med Plus - 877 Oak Park Blvd., Pismo Beach, CA.
San Luis Obispo: Med Stop – 283 Madonna Rd, Suite B, SLO, CA 93405
(805) 226-4222
(805) 474-8450
(805) 549-8880
REV 8/2019
P.O. Box 8106
San Luis Obispo, CA 93403
Nursing & Allied Health Department
Main Office: CA Highway 1, Bldg. 2700, Room 2722
San Luis Obispo, CA 93405
Phone (805) 546-3100, ext. 2798 Fax (805) 546-3961
Injury/Exposure Report
PART 2: Student Statement
STUDENT NAME:
STUDENT ID # (begins with "900")
STUDENT MAILING ADDRESS:
STUDENT PHONE NUMBERS (CELL & HOME):
DATE & TIME OF INJURY/EXPOSURE:
LOCATION OF OCCURRANCE:
COURSE TITLE AND INSTRUCTOR NAME:
DESCRIPTION OF INJURY/EXPOSURE:
I decline medical treatment for the above injury/exposure: ________ (student’s initials)
If declining medical treatment, state reason:
Completed & signed by:
Date:
STUDENT’S RESPONSIBILITY:
For Office Use Only
1.
Program:
2.
Start Date:
3.
For ALL incidents/exposures: IMMEDIATELY report injury/exposure to Cuesta Instructor.
Complete Part 2, Student Statement, of the Injury/Exposure Report and submit it to your
Cuesta Instructor. Instructor will submit this form to the Nursing or Allied Health office.
The student will be contacted by the Cuesta College Human Resources Office regardless of
injury, exposure, and/or acceptance or declination of treatment.
Treatment
Received?
Yes
No
Follow-up
Required?
Yes
No
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Completed 7 February 2020

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