CMC Student/Visitor Injury Report Form

Name of person injured Name of person injured First Last
Is person a student or a visitor?

Is person a student or a visitor? Student Visitor
Contact information for injured person
Phone Contact information for injured person
Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date of injury Date of injury / MM / DD YYYY
Time of injury Time of injury : HH MM AM/PM
Physical campus location where injury occurred
Describe injury in detail (location on body, type of injury).
Describe what person was doing immediately preceding the injury.
Describe how injury occurred.
Describe any first aid rendered at scene, including who provided the aid.
Was person referred for further medical treatment?

Was person referred for further medical treatment? Yes No
If yes, please describe:
Did person refuse first aid or medical treatment?

Did person refuse first aid or medical treatment? Yes No
Where did injured person go after the incident (i.e., hospital, doctor's office, returned to campus activity)?
For lab injuries, please list all substances and objects involved. Was the person wearing protective gear? if not, should the person have worn protective gear?
Identify all witnesses to the injury, including their contact information.
Was Campus Safety contacted?

Was Campus Safety contacted? Yes No
Were any other CMC employees notified of the injury?

Were any other CMC employees notified of the injury? Yes No
If yes, please identify them.
If possible, please upload photos of the injury and/or where the injury occurred. You may upload up to five photos of no more than 2 MB each.

Attach Files
List any additional information here.
Name of person submitting report Name of person submitting report First Last
Contact information for person submitting report
Phone Contact information for person submitting report
Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country