STUDENT ACCIDENT REPORT FORM - Iowa State University
STUDENT ACCIDENT REPORT FORM
Office of Risk Management
Iowa State University
The injured student or department representative should fill out this form
|Name: | | |Curriculum: | |
|Address: | | |Phone: | |
|Date: | | |Time accident occurred: | |
|Sex: Male or Female |(circle one) |Age: | |
|Room or area in which accident occurred: | |
| |
|Description of Accident: Please describe how the accident happened. What was the student doing? List any specific acts by individuals or conditions that led to |
|the accident. (include any tools, machinery or instrument involved) |
| |
| |
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| |
| |
| |
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|Nature of Injury |Part of Body Injured |
| | |Abrasion | | |Cut | | |
| | | | | | |
| | | | | | |
|Did accident occur during class time? Y or N If yes, provide class name: | |
|Was first aid administered? Y or N |
|Did you go to the Student Health Center for treatment: Y or N |
|Name of physician: | |
|Remarks: What recommendations do you have for preventing other accidents of this type? |
| |
|Signed: | | | |
| |Student | |Department Representative |
Mail Original to: Office of Risk Management, 3618 Administrative Services Building, Ames, Iowa 50011-3618
NOTE: Students employed by ISU who are injured while at work should fill out the First Report of Injury form. (Call 294-3753, Human Resource Services, Workers Compensation Office for copy)
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