"Incident Reporting Form - Angelina College"

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Angelina College
Incident Reporting Form
Information
Name:
Date:
Age:
Time:
Incident
Contact
Location:
Number:
Contact
Status:
Employee
Student
Visitor
Number:
Type of Incident
Chemical Exposure
Blood Borne Exposure
Violation of Safety Rules
Physical Injury
Other:
Details
Nature of Incident:
Action Taken:
Follow Up:
Acknowledgement
Signature:
Date:
Witness Signature:
Date:
Signature of Person filing form:
Date:
Angelina College
Incident Reporting Form
Information
Name:
Date:
Age:
Time:
Incident
Contact
Location:
Number:
Contact
Status:
Employee
Student
Visitor
Number:
Type of Incident
Chemical Exposure
Blood Borne Exposure
Violation of Safety Rules
Physical Injury
Other:
Details
Nature of Incident:
Action Taken:
Follow Up:
Acknowledgement
Signature:
Date:
Witness Signature:
Date:
Signature of Person filing form:
Date:
Please mark location of injury on diagram.
Left
Right
Statements reported by injured person:________________________________________
________________________________________________________________________
________________________________________________________________________
Observations made regarding injury:__________________________________________
_______________________________________________________________________
_______________________________________________________________________
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