Harper College
Student Incident/Injury Report
(To be completed by the student and instructor and signed by both.)
Send completed form to the Manager, Env. Health & Safety, Sara Gibson – sgibson@harpercollege.edu 2/2018
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:
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):
Harper Health Services
Date:
Immediate Care Clinic
Date:
Hospital/ER
Date:
Personal Physician
Date:
(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.)
Signature: Date:
Signature: Date:
