Accident/Incident Report

Name of Injured or Claimant:

Phone:

Address:

Age:

 

Gender:

Status:

    ____Student 1        _______Faculty 2             ________Staff 2                  _______Other 3

Date / Time Accident Occurred:

Location where accident Occurred:

Date / Time Accident Reported to Department:

 

 

 

Witnesses:  Name

Address

Phone

 

 

 

 

 

 

Persons Interviewed: Name

Address

Phone

 

 

 

 

 

 

Describe the facts of the accident in detail, including immediate actions taken (use attachments if necessary):   

 

Nature of suspected/stated injury or illness (e.g., abrasion, sprain, fracture, etc.):

 

Part of body injured:

 

Was first-aid/medical attention refused?

_________ Yes

_________ No

What medical attention was provided and by whom: 

 

Prior medical condition (s) known?

 

___ Yes

___ No

If yes, Please Describe:

 

Prepared by: Name/Title (Print)

 

Reviewed by: Supervisor (Print)

 

Signature:

 

Signature:

 

Department:

 

Department:

 

Phone:

 

Phone:

 

Date:

 

Date:

 

1 – Student:  If the injury is serious, notify Risk Management immediately and send copies of this form to Risk Management at 3162 or fax  (208) 885-9490, Environmental Health & Safety, 2030 or fax (208) 885-5969, Vice-President for Student Affairs at 4253, and Dean of Students at 2431.  Keep copy on file for at least 3 years.

2 – Faculty of Staff:  Work-related injuries must be reported to Environmental Health & Safety (208) 885-6524 as soon as possible.

3 – Other:  If the injury is serious, notify Risk Management immediately and send copies of this form to Risk Management at 3162 or fax (208) 885-7177 and Environmental Health & Safety at 2030 or fax (208) 885-5969.  Keep copy on file for at least 3 years.

 

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