Non-Employee Injury Report Form printable pdf download

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

Non-Employee Injury Report Form

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