Campus Incident/Accident Report Form

Name

First Last

Status

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sex

Male
Female

Age

Place of Accident:*

Building Name*

Grounds Location*

Specify Other Location*

Responsible Person/Next of Kin:

Name

First Last

Phone

Relationship

Was responsible person notified?

Yes
No

By Whom Notified:

Date and Time of Notification

Area of Injury:

Select All that Apply*

Other Specify:

Exposure*

Were you exposed to any bodily fluids or chemicals?

Yes
No

If yes, please explain:

Emergency Care Rendered:

Was emergency care rendered?*

Yes
No

What emergency care was provided? (Select All that Apply):*

Other Specify:*

Why was emergency care not rendered?*

Refused Treatment
Other

Action Taken on Accident:

Select All that Apply

EMS Phoned: By Whom?

First-Aid Provided: By Whom?

Sent Home: By Whom?

Sent to Physician: By Whom?

Sent to Hospital: By Whom?

Name of Hospital

School Information

Reported by:*

Department

Witness:

Date

Time

:

Comments

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Head
Face
Eye(s)
Neck
Left shoulder, arm, hand
Right shoulder, arm, hand
Chest
Back
Pelvis
Abdomen
Buttock
Left hip, thigh, leg, foot
Right hip, thigh, leg, foot
Other

Oral Airway
CPR
Controlled Bleeding
Bandaged Wound
Spinal Immoblization
Applied Splint
Applied Traction
Applied Restraints
Obstetrical – Delivery
Other

EMS Phoned
First Aid Treatment
Sent Home
Sent to Physician
Sent to Hospital