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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