HCCSC Employee/Visitor Accident Report

HUNTINGTON COUNTY COMMUNITY SCHOOL CORPORATION

Huntington County Community School Corporation
Is the injured person an employee of HCCSC?
School location where injury occured?
Are you a Food Service Employee?
Food Service Director Email
example@example.com
Clinic Email
example@example.com
Name

First NameLast Name
Address

Address

Street Address Line 2

CityState

Zip
Telephone Number
Format: (000) 000-0000.
Gender
Date of Birth

MonthDayYear
Date
Department/Occupation
Hours Worked Per Day
Days Worked Per Week
Date of Injury

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Exact Address of Accident
Nature of Injury (bruise, cut, sprain, etc...)
Please use this diagram to complete the next sections:
Injury Area
Eye
Shoulder
Arm
Elbow
Wrist
Hand
Finger (please Specify)
Hip
Leg
Knee
Ankle
Foot
Toe (Please Specify)
Other
Type of Injury
Pain (Type of Inujury)
Other (Type of Injury)
Describe Fully How Accident/Exposure Occurred (be specific as to tools or material being handled, what employee/visitor was doing, how accident occurred)
How Was Injury Treated (first aid on site, clinic, hospital, etc...)
Was Physician Contacted?
Name of Physician
Name of Hospital Referred?
Was there a Witness to the incident?
Name of Witness

First NameLast Name
Phone Number of Witness
Please enter a valid phone number.Format: (000) 000-0000.
Email of Witness
example@example.com
Have you ever injured this body part before?
If so, when?

MonthDayYear
Date
Are you currently receiving medical treatment for the prior injury?
What do you believe caused this accident?
What can be done to prevent this from happening in the future?
Signature of Injuried person

Clear
Date

MonthDayYear
Date
Supervisior Email
example@example.com
Supervisors Signature

Clear
Date

MonthDayYear
Date
Should be Empty: