STUDENT INJURY REPORT PERSONAL INFORMATION: HOME PHONE CELL PHONE/WORK PHONE X STUDENT________________________E#: NAME: ADDRESS (STREET & NO.) CITY / STATE ZIP CODE EMAIL ADDRESS NAME OF PROGRAM / DEPARTMENT ☐UNDERGRAD PROGRAM YEAR IN STUDY: ☐ ☐ ☐PA ☐ ☐NURSING ☐PHARMACY ☐1ST☐2ND AT OT PT X GRADUATE PROGRAM ☐RESPIRATORY CARE ☐CERTIFICATE PROGRAM ☐ 3RD ☐4TH INCIDENT / DAMAGE DETAILS: COMPLETE THIS SECTION FOR PERSONAL INJURIES: PRIMARY BODY PART SEVERITY OF INJURY CAUSE OF INJURY (BE TREATED BY ☐ NO REPORTED INJURY SPECIFIC) ☐EMERGENCY ROOM AFFECTED ☐ OBJECT (MACHINERY) ☐ MINOR FIRST-AID ☐PRIMARY CARE RIGHT or LEFT ☐EQUIPMENT / TOOLS ☐ SEVERE PHYSICIAN ☐☐HEAD ☐HAZARDOUS DISABLING ☐ OTHER_Urgent Care ☐☐NECK SUBSTANCE ☐ ☐REFUSED TREATMENT ☐NEEDLE STICK ☐☐SHOULDER ☐BODY FLUID EXPOSURE . ☐☐ARM ☐FALL ☐☐ELBOW ☐OTHER________________ ☐☐WRIST ☐☐HAND LOCATION / ADDRESS OF ADDITIONAL BODY PART(S) AFFECTED: INJURY No ☐☐FINGER(S) ☐☐CHEST ☐☐HIP DESCRIPTION OF INJURY: ☐☐LEG ☐☐KNEE WITNESS OF INCIDENT REMARKS and NAME(s): ☐☐ANKLE ☐☐FOOT REMARKS CLINICAL SUPERVISOR’S NAME____________________________________________DATE: 2/19/15 ☐☐TOE(S) ☐☐OTHER REPORT COMPLETED BY: DATE REPORTED TIME REPORTEDAMPM PHONE: EMAIL E-MAIL COMPLETED REPORT TO Melissa Cloyd, MPA | Information Research Technician II / Clinical Education Information Coordinator cloydmc@etsu.edu | Phone: 423.439.8707 A copy of this form is kept by the program in the student’s file and sent to the Dean of CCHRS.
STUDENT INJURY REPORT PERSONAL INFORMATION: X STUDENT________________________E#: HOME PHONE CELL PHONE/WORK PHONE NAME: ADDRESS (STREET & NO.) CITY / STATE ZIP CODE EMAIL ADDRESS NAME OF PROGRAM / DEPARTMENT ☐ AT ☐ OT ☐PA ☐ PT ☐NURSING ☐PHARMACY ☐RESPIRATORY CARE ☐UNDERGRAD PROGRAM X GRADUATE PROGRAM ☐CERTIFICATE PROGRAM YEAR IN STUDY: ☐1ST☐2ND ☐ 3RD ☐4TH INCIDENT / DAMAGE DETAILS: COMPLETE THIS SECTION FOR PERSONAL INJURIES: PRIMARY BODY PART AFFECTED RIGHT or LEFT ☐☐HEAD ☐☐NECK ☐☐SHOULDER ☐☐ARM ☐☐ELBOW ☐☐WRIST ☐☐HAND ☐☐FINGER(S) ☐☐CHEST ☐☐HIP ☐☐LEG ☐☐KNEE ☐☐ANKLE ☐☐FOOT ☐☐TOE(S) ☐☐OTHER SEVERITY OF INJURY ☐ NO REPORTED INJURY ☐ MINOR FIRST-AID ☐ SEVERE ☐ DISABLING . CAUSE OF INJURY (BE SPECIFIC) ☐ OBJECT (MACHINERY) ☐EQUIPMENT / TOOLS ☐HAZARDOUS SUBSTANCE ☐NEEDLE STICK ☐BODY FLUID EXPOSURE ☐FALL ☐OTHER________________ TREATED BY ☐EMERGENCY ROOM ☐PRIMARY CARE PHYSICIAN ☐ OTHER_Urgent Care ☐REFUSED TREATMENT LOCATION / ADDRESS OF INJURY ADDITIONAL BODY PART(S) AFFECTED: No DESCRIPTION OF INJURY: WITNESS OF INCIDENT REMARKS and NAME(s): CLINICAL SUPERVISOR’S REMARKS NAME____________________________________________DATE: 2/19/15 REPORT COMPLETED BY: PHONE: EMAIL DATE REPORTED TIME REPORTEDAMPM E-MAIL COMPLETED REPORT TO Melissa Cloyd, MPA | Information Research Technician II / Clinical Education Information Coordinator cloydmc@etsu.edu | Phone: 423.439.8707 A copy of this form is kept by the program in the student’s file and sent to the Dean of CCHRS.
pt_student_injury_report_accessible_2017.docx