Student-Visitor Injury Report Form Scripps College Student/Visitor Injury Form 1. Name of the injured person (first and last name)(required) 2. Phone Number of injuried person (cell phone preferred)(required) 3. Is person a student or a visitor? (required) Student-Scripps College Student-Pitzer College Student-Harvey Mudd College Student-Pomona College Student-Claremont Mckenna College Visitor 4. Street Address of injuried person(required) Address Line 2 City(required) State(required) Zip Code(required) 5. Date of injury (YYYY-MM-DD)(required) 6. Time of Injury(required) 7. Physical campus location where injury occurred (building name and room number or courtyard name)(required) 8. Describe injury in detail (location on body, type of injury). (required) 9. Describe what the person was doing immediately preceding the injury. (required) 10. Describe how injury occurred. (required) 11. Describe any first aid rendered at the scene, including who provided the aid. (required) 12. Was person referred for further medical treatment?(required) Yes No If yes, please describe: 13. Did person refuse first aid or medical treatment? (required) Yes No 14. Where did the injured person go after the incident (i.e., hospital, doctor's office, returned to campus activity)? (required) 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? (required) 15. Identify all witnesses to the injury, including their contact information. (required) 16. Was Campus Safety contacted? (required) Yes No 17. Were any other employees notified of the injury? Please list full first and last name and contact information.(required) 18. List any additional information here. 19. Name of person submitting report-First Name(required) 20. Name of person submitting report-Last Name(required) 21. Contact information for person submitting report-phone number and email address(required) Please email any photos to [email protected] Submit Δ
