General Accident Report Form

COMPLETE REPORT WITHIN 24 HOURS OF ACCIDENT AND ROUTE REPORT TO SECURITY, CC-123.

Personal Information:
Name of injured person _______________________________________________________________________________________
❑ Student ❑ Employee ❑ Visitor ❑ Co-op child ❑ Work study ❑ CWE
Home address _____________________________________ Home phone _____________________________ ❑ Male ❑ Female
Date of birth ____________________ Personal health/accident insurance _______________________________________________
ID number _________________________ LBCC department _______________________________________ Ext. # ___________
Supervisor/instructor ______________________________________________________________________ Notified? ❑ Yes ❑ No

Injury/Illness Information:
Date of accident/illness _____________________________________________ Time ______________________________________
Location (building, room) ____________________________ Address (if off campus) ______________________________________
Person was in: ❑ Class ❑ Work situation* ❑ Other ___________________________________________________________
Describe injury (part of body affected) ___________________________________________________________________________
Describe how accident happened _______________________________________________________________________________
__________________________________________________________________________________________________________
Describe why injury/illness occurred and basic cause (wrong equipment, lack of training, unsafe condition, etc.) _________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

Names of witnesses (include address/phone number):

__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Person filing report (print) _____________________________________________________ Phone # _______________________
Signature ______________________________________________________________________ Date _______________________

TO BE COMPLETED BY SUPERVISOR/INSTRUCTOR/SAFETY COORDINATOR

Recommendation to prevent reoccurrence; resolutions/actions taken:

__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Name of instructor or supervisor _____________________________ Signature _________________________________________

First aid administered by ___________________________________________________________________________________

Describe first aid administered, transport to medical facility by whom __________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________

*Employee and workstudy on-the-job injuries/illnesses that require medical attention or involve time loss are to be recorded on a
Worker’s Compensation, OR State 801 form, available in the Human Resources Office, CC-113.
CC: Safety Coordinator _______________ Human Resources _________________ Adm. & Student Services __________________
Revised 5/20/04