ACCIDENT / INCIDENT REPORT
FORM
VIRGINIA TECH - OFFICE OF RISK
MANAGEMENT
BLACKSBURG, VA. 24061-0310
540-231-7439
FAX-540-231-5064
Name of Responsible
Office______________________________________ Date of Report ___________________
Name of Responsible Virginia Tech
Representative ___________________________________________________
Address of Office __________________________________State ______ Zip _________ Phone ______________
Name of Injured Person(s) or Involved
Person(s)___________________________________Age ______ Sex _____ Address
__________________________________________State ______ Zip _________ Phone ______________
Name of Injured Person(s) or Involved
Person(s)___________________________________Age ______ Sex _____ Address
__________________________________________State ______ Zip _________ Phone ______________
Name of Parent or Guardian(if minor)
___________________________________________Age ______ Sex _____ Address
__________________________________________State ______ Zip _________ Phone ______________
Name/Addresses of Witnesses (Each Witness
Should Attach a Signed Statement of What Happened):
1.
__________________________________________________________________________________________
2.
__________________________________________________________________________________________
3.
__________________________________________________________________________________________
Type of Incident : Behavioral
Accident
Illness
Other ___________________________________
Date of Incident/Accident: Hour ________(am or
pm) Day ________ Month _________
Year _______
Describe
the Incident in Detail
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
|
|
Location
Of Incident and Diagram Showing
Objects and Persons
What
Activity was the Injured Participating in at the Time of the
Incident___________________________
______________________________________________________________________________________
______________________________________________________________________________________
Describe any Equipment Involved in the
Incident______________________________________________
Describe Emergency Procedures Followed as a Result of
this Incident:_____________________________
MEDICAL
REPORT OF INCIDENT
Were
the Parents or Guardian Notified ? Yes No
How?__________________________________
By
Whom?____________________Title_______________When_________________________________
Response
of Individual
Notified____________________________________________________________
______________________________________________________________________________________
Where
was Treatment Given At Accident Site DoctorÕs Office
Hospital
Rescue Squad
Describe
Treatment Given ____________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________
Treatment
Given by Whom?________________________________ Date of Treatment ______________
Was
Injured Retained Overnight in Hospital?
Yes No
If Yes, Where ________________________
Name
of Attending Physician
_____________________________________________________________
Prognosis
of Injured at the Time of
Report___________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Comments____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Person
Completing
Report_______________________Signature________________________________
Position_____________________Phone______________________Fax___________________________
THIS
ACCIDENT/INCIDENT REPORT IS NOT REQUIRED FOR INCIDENTS SUCH AS SCRAPES, BRUISES, SPRAINS, ETC. THIS INCIDENT REPORT
IS REQUIRED FOR SERIOUS ILLNESSES, SIGNIFICANT BEHAVIORAL PROBLEMS OR ACCIDENTS
INVOLVING INJURIES LIKE FRACTURED BONES, CHIPPED OR BROKEN TEETH, EXTENSIVE
LACERATIONS INVOLVING SUTURES, FALLS INVOLVING UNCONCIOUSNESS, DISLOCATIONS,
INCIDENTS INVOLVING WATER WHICH REQUIRE RESUSCITATION, OR ANY INJURY REQUIRING
HOSPITAL STAY.
THIS ACCIDENT/INCIDENT REPORT IS ALWAYS REQUIRED WHEN THE PROCEDURES OUTLINED ON THE EMERGENCY RESPONSE CARD AND CARRIED BY ALL COOPERATIVE EXTENSION REPRESENTATIVES ARE INITIATED. ONCE COMPLETED THE FORM SHOULD BE FAXED TO 540-231-5064 AND MAILED THE VIRGINIA TECH OFFICE OF RISK MANAGEMENT.