Student or Visitor Injury/Illness Report Template - California State University

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STUDENT OR VISITOR
INJURY /ILLN ESS
Case Number
REPORT
PART I – TO BE COMPLETED BY INJURED/ILL OR REPORTING PERSON
Name
Campuswide ID
Date of Birth
Extension
Street
City
State
Zip
Home Phone Number
Sex
Department or Sponsoring Organization
Student
Student Assistant
Male
Female
Student on Work Study
Visitor
Activity During Accident / Illness
Attending Class, Lab, etc.
Research
Field Trip
Club or Organization
Free Time
Other___________
Sports Activity
P.E. Class
Intramurals
Intercollegiate
Unsupervised
Specific Sport___________________________________________
Name of Coach or Witness Present______________________________
Medical Treatment Provided:
Yes
No
Returned to Activity:
Yes
No
Describe the injury/illness, including what, where, why, how the injury/illness occurred:
Date:_________________________________ Time:__________________________ Location: ___________________________________
Signature (If able)
Date
Report Completed By
Date
Phone Number
PART II – TO BE COMPLETED INSTRUCTOR, DEPARTMENT CHAIR OR AUTHORIZED
REPRESENTATIVE OF THE ORGANIZATION CONDUCTING THE ACTIVITY
Date of Injury / Illness / Death
Date of knowledge of Injury
Time of Injury / illness
Hour_____
A.M
P.M.
Describe the injury/illness, including what, where, why, how the injury/illness occurred:
What has been done to correct any condition that might have contributed to the injury / illness?
What do you recommend for correction?
Part of Body (check)
Type of Injury (check)
Name of Witness / Dept / Phone #
Indicate Right of Left when Applicable
1.
Head
10.
Wrist
19.
Neck
1.
Reaction to foreign substance/objects
1.
2.
Face
11.
Hand
20.
Shoulder
2.
Puncture
3.
Eye
12.
Finger
21.
Groin
3.
Laceration
4.
Ear
13.
Knee
22.
No Injury
4.
Confusion
2.
5.
Mouth 14.
Leg
23.
Other
5.
Burn
6.
Heart
15.
Ankle
___________
6.
Fracture
7.
Back
16.
Foot
7.
Amputation
3.
8.
Trunk 17.
Toe
8.
Sprain/Strain
9.
Arm
18.
Hip
9.
Other__________________________
Instructor’s / Reporting Party Name
Title
Date
Extension
Contact Information
Department Head Signature (if injured is a student)
Title
Date
Extension
Contact Information
EHS, RM (10/15)
Distribution: Risk Management CP700, EHS-T-1475, Supervisor
STUDENT OR VISITOR
INJURY /ILLN ESS
Case Number
REPORT
PART I – TO BE COMPLETED BY INJURED/ILL OR REPORTING PERSON
Name
Campuswide ID
Date of Birth
Extension
Street
City
State
Zip
Home Phone Number
Sex
Department or Sponsoring Organization
Student
Student Assistant
Male
Female
Student on Work Study
Visitor
Activity During Accident / Illness
Attending Class, Lab, etc.
Research
Field Trip
Club or Organization
Free Time
Other___________
Sports Activity
P.E. Class
Intramurals
Intercollegiate
Unsupervised
Specific Sport___________________________________________
Name of Coach or Witness Present______________________________
Medical Treatment Provided:
Yes
No
Returned to Activity:
Yes
No
Describe the injury/illness, including what, where, why, how the injury/illness occurred:
Date:_________________________________ Time:__________________________ Location: ___________________________________
Signature (If able)
Date
Report Completed By
Date
Phone Number
PART II – TO BE COMPLETED INSTRUCTOR, DEPARTMENT CHAIR OR AUTHORIZED
REPRESENTATIVE OF THE ORGANIZATION CONDUCTING THE ACTIVITY
Date of Injury / Illness / Death
Date of knowledge of Injury
Time of Injury / illness
Hour_____
A.M
P.M.
Describe the injury/illness, including what, where, why, how the injury/illness occurred:
What has been done to correct any condition that might have contributed to the injury / illness?
What do you recommend for correction?
Part of Body (check)
Type of Injury (check)
Name of Witness / Dept / Phone #
Indicate Right of Left when Applicable
1.
Head
10.
Wrist
19.
Neck
1.
Reaction to foreign substance/objects
1.
2.
Face
11.
Hand
20.
Shoulder
2.
Puncture
3.
Eye
12.
Finger
21.
Groin
3.
Laceration
4.
Ear
13.
Knee
22.
No Injury
4.
Confusion
2.
5.
Mouth 14.
Leg
23.
Other
5.
Burn
6.
Heart
15.
Ankle
___________
6.
Fracture
7.
Back
16.
Foot
7.
Amputation
3.
8.
Trunk 17.
Toe
8.
Sprain/Strain
9.
Arm
18.
Hip
9.
Other__________________________
Instructor’s / Reporting Party Name
Title
Date
Extension
Contact Information
Department Head Signature (if injured is a student)
Title
Date
Extension
Contact Information
EHS, RM (10/15)
Distribution: Risk Management CP700, EHS-T-1475, Supervisor

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