Non-employee Injury Report Form - Citrus Community College District

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Citrus Community College District
Non-Employee Injury Report Form
SUBMIT THIS FORM WITHIN 24 HOURS to the OFFICE OF HUMAN RESOURCES
Date of this Report: _____________ A report of injury to a: ____ Visitor ___ Student
Name of Injured: _____________________________ Date of Accident: ______________________
Address & Phone #: _________________________________________________________________
Location: Where did the Accident occur? (Please be specific; inside/outside of building (name),
Room #, near what landmarks, etc:______________________________________________________
Describe the Incident:
(Facts
Only. Exclude opinions/assumptions as to cause):
____________________________________________________________________________________
____________________________________________________________________________________
Witness(es) if any. Include their Address & Phone:
What is the observable nature of the Injury?
___ Scrape
___ Fracture ___ Strain/Sprain
___ Bruise
___ Laceration
___ Internal
___ Puncture Wound
___ Cut
___ Other (please describe): ____________________________________________________________
Body part(s) injury:
___ Head
___ Face
___ Eye
___ Neck
___ Chest
___ Abdomen
___ Back
___Shoulder ___ Arm
___ Elbow
___ Wrist
___ Hand
___Finger
___ Leg
___ Ankle
___ Foot
___ Toe
Other: ___________________________________
Corrective Action: What changes or actions would you recommend be taken to prevent this
accident from occurring again? _________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Other Comments:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Signature of Injured: ________________________________ Date: _______________________
DISTRIBUTION: Original to Human Resources | Copy to Environmental Health and Safety Office
Citrus Community College District
Non-Employee Injury Report Form
SUBMIT THIS FORM WITHIN 24 HOURS to the OFFICE OF HUMAN RESOURCES
Date of this Report: _____________ A report of injury to a: ____ Visitor ___ Student
Name of Injured: _____________________________ Date of Accident: ______________________
Address & Phone #: _________________________________________________________________
Location: Where did the Accident occur? (Please be specific; inside/outside of building (name),
Room #, near what landmarks, etc:______________________________________________________
Describe the Incident:
(Facts
Only. Exclude opinions/assumptions as to cause):
____________________________________________________________________________________
____________________________________________________________________________________
Witness(es) if any. Include their Address & Phone:
What is the observable nature of the Injury?
___ Scrape
___ Fracture ___ Strain/Sprain
___ Bruise
___ Laceration
___ Internal
___ Puncture Wound
___ Cut
___ Other (please describe): ____________________________________________________________
Body part(s) injury:
___ Head
___ Face
___ Eye
___ Neck
___ Chest
___ Abdomen
___ Back
___Shoulder ___ Arm
___ Elbow
___ Wrist
___ Hand
___Finger
___ Leg
___ Ankle
___ Foot
___ Toe
Other: ___________________________________
Corrective Action: What changes or actions would you recommend be taken to prevent this
accident from occurring again? _________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Other Comments:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Signature of Injured: ________________________________ Date: _______________________
DISTRIBUTION: Original to Human Resources | Copy to Environmental Health and Safety Office

Download Non-employee Injury Report Form - Citrus Community College District

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