CLINICAL/PRACTICUM STUDENT
INCIDENT/ACCIDENT REPORT FORM
1. Student’s Description of Accident
2. Faculty Member’s Description of Accident:

CLINICAL/PRACTICUM 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 Clinical/Practicum Faculty Member - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Name: Title

Cell/Daytime Phone Program

Description of 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 Director’s Signature Date

Original – Delgado Compliance Office; Copies – Student, Faculty Member, Program Director

Form 2610/001 (7/10)