Appendix B(3) NON-EMPLOYEE ACCIDENT_INJURY REPORT FORM
- Laura Lehman (Deactivated)
Instructions:
1. Assist the injured party in receiving medical attention as needed.
2. Complete the form promptly (in ball-point pen) for incidents involving injury or potential injury to students and visitors.
3. Return completed form as follows:
- Science Center injuries return to the Chemical Hygiene Officer
- Other injuries return to the Human Resources Office
Person reporting injury: Date Reported:
Date of injury: Time: a.m. p.m.
Name
Address
Street City State Zip
Telephone Number (Day) (Night)
___Student ___Visitor ____Leasee
Accident Location
Instructor (if applicable)
Course (if applicable)
Injury Suffered
Cause of Injury
Description of immediate first aid administered or action taken:
Administered by
Was further treatment or follow-up treatment suggested? ____ yes ____no
If so, what? ____EMU Health Center ____ RMH ____ Rescue Squad __________________ Other
Witnesses
Name Phone #
Name Phone #
Suggestions for future avoidance
Reported to Campbell Insurance
Date Time Initials