Fillable Printable Injury Report Form - University Of Northern Colorado
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 OfficeNHS Dean's OfficeKeep a copy for yourself
1Injured Party
AddressTelephone Number
Address
2Sex:MFDOBMarriedSingle
3Date of InjuryTimeA.M. P.M.
4Location of Injury
5Name of Person in Charge
Title
Telephone number:WorkHome
6Class or Activity:
7AbrasionLacerationAmputationPoisoningJoint
PunctureBiteScaleRadiationBruise
ScratchesBurnSprainCutJoint
AsphyxiationElec. ShockBone
Other
8AbdomenFootAnkleHandArm
HeadBackKneeChestLeg
EarMouthElbowNoseEye
ScalpFaceTeethFingerWrist
Other
9Description of Accident (What Happened)
Identify equipment used
10Immediate Action Taken (Check all that apply)
First AidbySent to Health Serviceby
Sent HomebySent to Hospitalby
Sent to DoctorbyName of Hospital
Was Parent or other individual notified? Yes NoNot ApplicableName and Relationship
11Specific Location/Bldg/Room # where injury occurred (Gunter/Butler-Hancock/Ross/BNCC/RSVP)
Athletic FieldGymnasiumStairwayClassroomLaboratory
CorridorOf ficePoolField TripRestroom
ShowerLocker RoomOther
12WitnessWitness
AddressAddress
Tele. #Tele #
13I attest that the above information, to the best of my knowledge, describes the cited incident.
WitnessStaff
SignatureDateSignatureDate
15Signature of injured party/dateSignature 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
1Attach lesson plan or describe the activity as you presented it for the day in which the incident occurred.
2What suggestion do you have, following this incident, for administrative action?
Staff SignatureDate
