HCCSC Employee/Visitor Accident Report

HUNTINGTON COUNTY COMMUNITY SCHOOL CORPORATION

Huntington County Community School Corporation
Is the injured person an employee of HCCSC?*

YesNo
School location where injury occured?*
Are you a Food Service Employee?

YesNo
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*
Gender*

MaleFemale
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*

HeadEyeShoulderArmElbowWristHandFingerBackChestAbdomenPelvisHipLegKneeAnkleFootToeOther
Eye*

LeftRight
Shoulder*

LeftRight
Arm*

LeftRight
Elbow*

LeftRight
Wrist*

LeftRight
Hand*

LeftRight
Finger (please Specify)*
Hip*

LeftRight
Leg*

LeftRight
Knee*

LeftRight
Ankle*

LeftRight
Foot*

LeftRight
Toe (Please Specify)*
Other*
Type of Injury*

AbrasionAmputationBiteBruiseBurnConcussionCut/LacerationForeign BodyFractureHearing impairedInfectionPainPunctureRash/DermRespiratoryStrain/SprainOther
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.
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: