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Student Information

Student Name

*

Date of Birth

Student ID

Address

City

State

Zip Code

Student Cell Phone Number

Student Home Number

Student Email Address

Name of Student鈥檚 Health Insurance Plan (If Available)

Emergency Contact Name

Emergency Contact Phone

Accident Injury Summary

Location where accident occurred

Was first aid rendered to student?

• Yes
• No
• Denied Treatment

If first aid was rendered to student, by whom?

Which body part(s) were injured

Was the student participating in a college class or sponsored event?

• Yes
• No

Was the student transported to the hospital?

• Yes
• No

If the student was transported to the hospital, how?

How did the accident occur? (Include equipment used, tasks undertaken, etc.)

What can be done to prevent future similar injuries?

Disposition of Student (back to class, recovering at home, hospital)

Police Report Taken?

• Yes
• No

Witness Information

Witness Name

Witness Phone