Fillable Printable Injury Report Form - University Of Northern Colorado

Injury Report Form - University Of Northern Colorado

UNIVERSITY OF NORTHERN COLORADO

COLLEGE OF NATURAL & HEALTH SCIENCES

Report all non-student, student or staff injuries which require treatment or might require treatment and which occur on the

UNC campus, or in college-sponsored activities elsewhere. Complete all items:

Turn form into: School Office NHS Dean's Office Keep a copy for yourself

1 Injured Party

Address Telephone Number

Address

2 Sex: M F DOB Married Single

3 Date of Injury Time A.M. P.M.

4 Location of Injury

5 Name of Person in Charge

Title

Telephone number: Work Home

6 Class or Activity:

7 Abrasion Laceration Amputation Poisoning Joint

Puncture Bite Scale Radiation Bruise

Scratches Burn Sprain Cut Joint

Asphyxiation Elec. Shock Bone

Other

8 Abdomen Foot Ankle Hand Arm

Head Back Knee Chest Leg

Ear Mouth Elbow Nose Eye

Scalp Face Teeth Finger Wrist

Other

9 Description of Accident (What Happened)

Identify equipment used

10 Immediate Action Taken (Check all that apply)

First Aid by Sent to Health Service by

Sent Home by Sent to Hospital by

Sent to Doctor by Name of Hospital

Was Parent or other individual notified? Yes No Not Applicable Name and Relationship

11 Specific Location/Bldg/Room # where injury occurred (Gunter/Butler-Hancock/Ross/BNCC/RSVP)

Athletic Field Gymnasium Stairway Classroom Laboratory

Corridor Of fice Pool Field Trip Restroom

Shower Locker Room Other

12 Witness Witness

Address Address

Tele. # Tele #

13 I attest that the above information, to the best of my knowledge, describes the cited incident.

Witness Staff

Signature Date Signature Date

15 Signature of injured party/date Signature of person completing report/date

Signature of School Director_________________________________________ Date_______________________________

UPON COMPLETION, PLEASE TAKE A COPY TO THE NHS DEAN'S OFFICE IN GUNTER 1000, CB 134

INJURY REPORT

UNIVERSITY OF NORTHERN COLORADO

ADMINISTRATIVE REPORT FORM.

FACULTY/STAFF MUST FILL OUT THIS FORM AND TURN IT INTO

THE DEAN'S OFFICE

1 Attach lesson plan or describe the activity as you presented it for the day in which the incident occurred.

2 What suggestion do you have, following this incident, for administrative action?

Staff Signature Date