Fillable Student Injury Assessment Form

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Student Injury Assessment Form

On average this form takes 8 minutes to complete

The Student Injury Assessment Form form is 2 pages long and contains:

  • 2 signatures
  • 13 check-boxes
  • 19 other fields

Country of origin: US
File type: PDF

U.S.A. forms for State University of New York at Farmingdale

BROWSE STATE UNIVERSITY OF NEW YORK AT FARMINGDALE FORMS

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Student Injury/Illness
Assessment Form
Environmental Health and Safety
Details
Date:
Time:
AM or PM
Location where injury/illness occured (i.e. bldg., room, etc.):
Date Reported:
Personal Information
Name:
Address:
Phone Number:
Type (Please check all boxes that apply)
Chemical Exposure
Needle stick
Bloodborne Pathogen Exposure
Burn/Scald
Scratch/Abrasion
Other (specify):
Incident
How did the injury/illness happen?
What caused the injury/illness?
Was the injury/illness witnessed by anyone? If so, please provide their name and contact information.
Are the hazardous conditions still present?
Yes (describe):
No
Name:
Signature:
Date:
To be completed by Environmental Health and Safety Officer
Follow-up and corrective actions:
Safety Officer:
Signature:
Date:
If the injury/illness is work related (i.e. paid internship, work study, etc.), describe your typical work functions (routine
tasks, daily activities, etc.) and provide supervisor’s and/or dean’s name and contact information.
Submit this form to:
Farmingdale State College
Environmental Health and Safety
Horton Hall
2350 Broadhollow Road
Farmingdale, NY 11735
ph.: (631) 420-2105
fax: (631) 420-9173
ehs@farmingdale.edu
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Student Injury Assessment Form

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Completed 18 November 2019

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