Fillable Student Visitor Incident Report Form (Montana Tech)

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Student Visitor Incident Report Form (Montana Tech)

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The Student Visitor Incident Report Form (Montana Tech) form is 1 page long and contains:

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  • 13 check-boxes
  • 23 other fields

Country of origin: US
File type: PDF

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1300 W. Park Street | Butte, MT 59701 | mtech.edu | 406.496.4463
STUDENT/VISITOR INCIDENT REPORT
NOTE: This report must be filled out completely and returned to Personnel within one working day of the incident.
PERSONAL INFORMATION
Name:
Date of incident:
Time of incident:
Local Address:
Phone number:
Name of person completing this report:
Campus Department:
INCIDENT INFORMATION
Who was notified of this incident? When? Include name(s) and department , date and time:
Exact location of incident:
Detailed description of what happened. Include what the person was doing at the time of the incident,
what object or substance caused injury if an injury occurred:
Body part injured (specify right or left if applicable):
Nature of injury (check all that apply):
Abrasion
Puncture
Sprain/strain
B Burn
Bruise
Foreign body in eye
Laceration
Heat Injury
Cold Injury
Other (specify)
TREATMENT REQUIRED
Yes No
Date of Treatment:
First Aid Only
Name of physician if seen
Hospitalized: Name of hospital:
WITNESSES TO THE INCIDENT:
Name:
Phone number:
Name:
Phone number:
Comments from witness: (attach additional
sheets if necessary:
Comments from witness:
________________________________________________ ___________________________________
Signature of Student or Visitor Date
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Student Visitor Incident Report Form (Montana Tech)

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Completed 25 July 2020

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