Fillable Student Incident Injury Report

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Student Incident Injury Report

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The Student Incident Injury Report form is 1 page long and contains:

  • 0 signatures
  • 5 check-boxes
  • 30 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Harper College

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Harper College
Student Incident/Injury Report
(To be completed by the student and instructor and signed by both.)
Student Name:
Harper ID#:
Email:
Home Address Street:
City:
Phone:
Date of Injury: Time:
Location of Injury (Bldg. room #):
Did the injury occur during class? Yes No
If yes, name of class and instructor:
DESCRIPTION (Write a detailed description of what, how and why the injury happened, including witnesses.)
EVALUATION (How could this injury be avoided in the future? Describe changes or improvements in equipment,
procedures, training and/or personal protective equipment needed.)
Student’s
Signature: Date:
Instructor’s
Signature: Date:
Send completed form to the Manager, Env. Health & Safety, Sara Gibson – sgibson@harpercollege.edu 8/2018
Nature of injury (slip/fall, struck by, strain, etc.):
Body part injured:
Was medical treatment obtained immediately following the injury? Yes No
Check location of treatment (check more than one if necessary):
Hospital/ER
D
ate:
NCH
Date:
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Student Incident Injury Report

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Completed 29 March 2020

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