THIS FORM IS NOT TO BE COMPLETED BY THE STUDENT!
PROMPTLY SEND THIS COMPLETED FORM TO RISK MANAGEMENT/DISTRICT OFFICE
Copy to VPA Office (Campus Safety Officer)
Revised 03/12
Today's Date: Date of Injury:
Time Injury Occurred:
Student Accident/Injury report taken by:
STUDENT INFORMATION
Student Name: Date of Birth: CSID:
Address: City: State: Zip:
Student Cell Phone #: Student Home #:
Name of Student’s Health Insurance Plan? (if applicable)
Emergency Contact Name: Emergency Contact Phone:
ACCIDENT / INJURY SUMMARY
Location where accident happened:
Was first aid rendered to student? Yes No By whom?
Which body parts were injured?
Was student participating in an intercollegiate event? Yes No
Was student transported by ambulance? Yes No
Exactly how did accident happen?
Disposition of Student: (back to class, home, E.R.?)
Police report taken? Yes No Name of Campus Police Officer:
HSR Student Accident form issued to student? Yes No
Date HSR Student Accident form issued:
WITNESS INFORMATION, (if applicable)
Witness Name: Witness Phone:
Signature of Person Completing Form:
STUDENT ACCIDENT/INJURY REPORT
CAMPUS NAME: MESA COLLEGE
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