INJURED PERSON [fills out this section]
_________________________________________________ ___________________________ _________________
Last Name First Name Middle initial G0 Number or SSN (last 4 digits) Birth date
________________________________________________
______________________________________________
Street City State Zip
Phone # (______)____________________________________ Check One: Student Employee Public Child Care
Location of incident:
WV___ MC___ Building/Room ________________________________ Date of Incident _______________ Time_____________
(Other location, please describe or attach maps)
For accidents in class or lab activities:
____________________________________________________ _________________________________________________
Instructor Name Course name
____________________________________________________ _________________________________________________
Other Witness/es Name(s) Phone No.
Injured Party: Please describe how accident/injury/incident occurred:
______________________________________________________________________________________
______________________________________________________________________________________
_________________________________ _________________________________ _______________
Print name of Injured Person Signature of Injured Person Date
COLLEGE PERSONNEL [only college personnel may fill out the following information]
Describe part of body affected, condition/ injuries (do not diagnose) __________________________________
___________________________________________________________________________
First Aid/ Treatment given ___________________________________________________________
___________________________________________________________________________
Referred to (check one): Emergency Facility MD Home
Other__________________________
Follow-up plans (if applicable) _________________________________________________________
Insurance (check one): Student Accident Insurance Worker’s Comp. Kaiser Medi-Cal Other __________
Was Accident Insurance information given to student: Yes No (If insurance needed, contact Student Health Services)
Yes
Did injured person’s blood or body fluid come in contact with student or staff? No
If yes who ___________________________ G0 # or SSN__________________ Phone # ________________
(Print Name) (Last 4 digits)
Did injured person’s blood or body fluid come in contact with any surface or equipment? Yes No
If yes, who decontaminated area, and how? _________________________________________________________
Employee accidents/ blood exposure must be reported and immediately faxed to: Venita Atwal in HR @ 741-2168; Fax#: 408-867-9059
_______________________________________ _________________________ _________________
Signature of College Personnel filling out form Dept. Date
Send completed form to Student Health Services WVMCCD Accident/Injury/Incident Report 9/2010.mcshs
WEST VALLEY MISSION COMMUNITY COLLEGE DISTRICT
ACCIDENT INJURY INCIDENT REPORT
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signature
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INSTRUCTIONS TO STAFF COMPLETING
ACCIDENT/ INJURY/ INCIDENT REPORT
1. TOP SECTION: Collect all identifying information about student, employee, or public
involved with accident/ injury/ incident. Have injured person complete theINJURED
PERSON” section, if possible. Make certain to put any instructor/ witness names on the
form. Complete in ink.
2. BOTTOM SECTION: Complete the “COLLEGE PERSONNEL” section. Report any first-
aid given and follow-up needed.
3. This completed report form should be sent immediately to Student Health Services
and a copy to injured person’s Supervisor. Health Services will distribute copies to
other college personnel as deemed appropriate.
4. Student injuries: The Incident Report is kept separate from student’s academic
records. This report is considered confidential.
IMPORTANT: If immediate corrective action needs to be taken at the location of the
incident, inform appropriate personnel IMMEDIATELY and indicate your
contact on the top of form. Some possible corrective actions are:
Corrective Action
Department
to Contact
Phone Numbers
Facility repair - electrical, plumbing, building, etc.
Blood or body fluid clean-up
Facilities
After 5 p.m.
Duty
Administrator
(408) 741-2050 or ext. 2050
After 5 p.m.
WVC 408- 593-2086
Mission 408 -590-2657
Building security
Hazardous materials spill
WVMCCD
Police
County Communication
408-299-2311
Request District Police
Additional Information describing accident or first aid treatment:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
WVMCCD Accident/ Injury/ Incident Report Instructions 9/2010.mcshs
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