REPORT OF STUDENT ACCIDENT/INJURY
Butte-Glenn Community College
Personal/Position Information
Name of Injured Student
/ /
Date of Birth Social Security No. Phone
Address City State Zip
M F
Insurance Coverage Sex
Injury Information
Date of Accident Hour Date Reported Hour
Accident Location
What was student doing when injured?
How did the accident occur?
Describe the injury or illness and part of body affected.
* Attach Witness statements
Action Taken:
1
st
Aid Given
Sent to Doctor
Ambulance Service
Sent Home
Sent to Student Health Services
Parent Called
Sent to Hospital
Other _________________________________________________________________________
Date Action Taken:
Time:
Did student return to class?
Yes
No
Date Returned:
Time
Witnesses
(If more space needed, use back of sheet.)
Name Phone
What steps have been taken to prevent a similar accident?
Completed By Date Time
Please Note: This form must be completed in ink and submitted to Student Health Services immediately
upon your knowledge of an accident. Report all possible unsafe conditions to Facilities Planning and
Management (895-2381).
Please return to Student Health Services (530 895-2441), Quad3, Room103
SHAR1 (8/03)
