Occupational Therapy Program Student Incident/injury Form

Please submit the following information to report a student incident or injury during a class, lab or school activity.

All fields marked with asterisk (*) are required.

required date field

Date of the Report:*

required text field

Name & Title of Person submitting report:*

required text field

Student Name:*

date field

Student DOB:

required date/time field

Date and Time of Incident:*

required text field

Facility Name:*

required textarea field

Location of Incident (e.g., Classroom, Lab, Fieldwork Site):*

required textarea field

Class/Activity in which incident/injury occurred:*

required textarea field

Nature of Incident (i.e., type of injury):*

required textarea field

Details of incident (i.e., how did the injury occur):*

checkbox field

Was student exposed to infectious fluids/materials:

Yes

required checkbox field

Was medical evaluation and treatment pursued by student:*

Yes

date field

Date treatment completed:

textarea field

Name of facility initiating and completing medical treatment:

textarea field

What corrective action do you think should be pursued to avoid reoccurrence?

Link (required)