West Virginia University Student or Visitor Accident Report Form
Constructed: Septemberr-19-2013 rev2 Carol A. Wells [Type text] [Type text]
STUDENT or VISITOR ACCIDENT REPORT FORM
West Virginia University
Environmental Health and Safety
THE INJURED STUDENT OR VISITOR AND WVU DEPARTMENT REPRESENTATIVE SHOULD COMPLETE THIS FORM.
Name:
Status:
(circle one) Student or Visitor
Phone:
Date:
Time accident occurred:
Sex: Male or Female
(circle one)
Age:
Building/Location and Room or area in
which accident occurred:
Description of Accident: Please describe how the accident happened. What was the injured person doing? List
any specific acts by individuals or conditions that led to the accident. (include any tools, machinery or
instruments involved)
Nature of Injury
Part of Body Injured
Abrasion
Cut
Scratch
Abdomen
Face
Leg
Amputation
Dislocation
Shock
Ankle
Finger
Mouth
Asphyxiation
Fracture
Sprain
Back
Foot
Nose
Bite
Laceration
Splinter
Chest
Forearm
Shoulder
Bruise
Poisoning
Strain
Ear
Hand
Teeth
Burn
Puncture
_
Fainted
Elbow
Head
Wrist
Concussion
Repetitive Stress Injury
Eye
Knee
Other specify)
Other (specify)
Was first aid administered? Y or N
Did you receive medical treatment? Y or N
Treatment location:
Signed:
or
Student
WVU Department Representative
Signed:
Visitor
E-Mail Original to: Carol.Wells@mail.wvu.edu , Mike.Gansor@mail.wvu.edu
West Virginia University Student or Visitor Accident Report Form
Constructed: Septemberr-19-2013 rev2 Carol A. Wells [Type text] [Type text]
