ࡱ> <>;} %bjbj55 4"__ P---8ey$-.:$n!CMMMCXMvMph $-X n0!~!!TTmCCMMMM! :  ý CLASSROOM / ON-CAMPUS INJURY INCIDENT REPORT: This form is to be used for all injuries or incidents occurring on campus, in classrooms or while participating in a College or District activity. Student / Visitor Name _____________________________ Soc Sec Number __________________________ Home Telephone No: ______________________________ Date of Birth __________________________ Address ____________________________________________ City ___________________ Zip ___________ Name of personal Physician _________________________________________ Phone No ________________ Address _________________________________________ City ___________________ Zip ______________ If covered by family insurance (HMO), name of insurance company ___________________________________ Address ____________________________________________ City ___________________ Zip ___________ Injury Date ________________ Injury Time ________a.m./p.m. Class (ie; Chem 1A) _________________ Class start time _______/ end time ________ Class Instructor: _____________________________ Actual location at time of Injury________________________________________________________________ Activity at time of accident ___________________________________________________________________ Part of body affected _______________________________________________________________________ Describe how injury/accident occurred _________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Witness/es________________________________________________________________________________ Instructor or staff member present/supervising ___________________________________________________ Is corrective action needed: Yes _______ No ______ If YES, please detail: _______________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Student Signature _____________________________________________ Date ___________________ Instructor/Supervisor Signature __________________________________ Date ___________________ Authorized District Signature ____________________________________ Date ___________________ Business Services comments (Steps taken to prevent a similar accident, follow up action taken)______________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Send completed form to Vice Chancellor, Business Services, 9800 Cody Street, Coalinga, CA 93210 or call Anne Jorgens at Ext. 2116 if you have any questions.      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