STATE OF MINNESOTA
INCIDENT REPORT
(To be completed by appropriate state employees and persons
involved in or observing an accident)
Name of Educational Institution:
Name of contact Person:
Phone Number:
Date of Accident:
Time:
Weather Conditions
Description of Incident (How where, and why):
Extent of Damage to Property:
Extent of Injury to Person(s):
Person(s)
Injured (Names, addresses, and telephone number’s):
Witnesses (Names, addresses, and telephone numbers):
Distribution:
Printed name of Person completing the form:
Signature (my signature indicates I
have retained a copy)
Office Address:
City, State, Zip
Office telephone No.:
Date of Report:
1. Remit original to:
Safety Officer, Box 43
Rochester Community & Technical College
851 30
th
Ave SE
Rochester, MN 55904
2. Copy to be retained by the Contact Person
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