Report of Accident/Incident Form

This form should be filled out by an immediate supervisor. Fill this form out for any accident/incident, robbery, etc. If the incident could be a worker's compensation claim the injured needs to ALSO fill out within 10 days an Industrial Incident Form available in Human Resources.

Information about the person involved/injured
This person was a:		Faculty/Staff Student Worker Volunteer Student Visitor
First Name:		M.I.
Last Name:
Street Address:
Address (cont'd):
City:
State (USA):		Choose One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Home Phone Number:		- -
Email Address:
Information about the Accident
Date of accident/incident:		Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2003 2004 2005 2006 2007 2008 2009 2010
Time of accident/incident:		: a.m. p.m.
Location of accident/incident/incident:
Please give an explanation of what happened. Include the cause of the injury or incident if known:
Please list any witnesses and their phone numbers:
First Name:		M.I.
Last Name:
Phone Number:		- -
First Name:		M.I.
Last Name:
Phone Number:		- -
First Name:		M.I.
Last Name:
Phone Number:		- -
When was accident/incident reported to the supervisor?
To whom was it reported?
First Name:		M.I.
Last Name:
Equipment/materials involved in the accident/incident/incident:
Was the accident/incident caused by another person not employed by Prescott College?
Yes No
If yes please enter their name and phone number:
First Name:		M.I.
Last Name:
Phone Number:		- -
Describe injury (part of body/type of injury):
Describe first aid/medical treatment (when; by whom):
Is this a job-related injury?		Yes No Unknown
Supervisor Information
First Name:		M.I.
Last Name:
Title:
Department:
Today's Date:		Month January February March April May June July August September October November December Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2003 2004 2005 2006 2007 2008 2009 2010
When you have completed all of the above information please select the submit button. If you do not complete a required field you will be asked to complete it.