TECHNICAL DIVISION WORK EXPERIENCE EDUCATION STUDENT
INCIDENT/ACCIDENT REPORT FORM
1. Student’s Description of Accident
2. Faculty Member’s Description of Accident:

TECHNICAL DIVISION WORK EXPERIENCE EDUCATION STUDENT

INCIDENT/ACCIDENT REPORT FORM

Information on Injured Student - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Name:

Last First Middle

Student ID Cell/Daytime Phone

Home Address:
(city/state/zip)

Information on Faculty Member - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Name: Title

Cell/Daytime Phone Program

Description of Incident/Accident - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Date of Incident/Accident

Exact Location of Accident (Name of business, full address, department involved)

Describe Equipment Being Used












First Aid Administered?
Yes	No	Doctor Seen? Yes No

Witnesses (include names, affiliation, and phone numbers if available):

Student’s Description of Accident

Student’s Signature _____________________________________________ Date ___________________

Faculty Member’s Description of Accident:

Faculty Member’s Signature ____________________________________________ Date ___________________

Program/Department Chair’s Signature
(or Assistant Dean, as applicable) ____________________________________ Date ___________________

Original – Delgado Safety & Risk Management Office; Copies – Student, Faculty Member, Program/Department Chair, Technical Division Dean

Form AA-003-01 (7/19)