Injury Report

Do not use for Workers' Compensation or illnesses.
All injuries should be reported within 24 hours.

Please keep a copy of this form for your records. 

* indicates a required field.

       
* Date of Injury  
  Time of Injury  

Information about the Injured

* Name of Injured Person  
* Temporary Address  
* Permanent Address  
  Home Phone  
  Cell Phone  
  Campus/Work Phone  
* Person is  
* Age  
* Birthdate  
* Gender  

Injury Information

 

  Program Participant? Camp
WC Performance Group
Field Trip
Other
 
  If other, please describe  
  Status of Person at Moment of Injury Student
Staff/Faculty
Visitor/Guest
Non-Student of WC
 
* Accident Location  
  Campus Building  
  Identification of Playing Field, Building Area, Room or Other:  
* How injury happened
 
  Witnesses (Name(s) and Phone Number(s))
 
* Injuries (suspected and known – include details such as right/left, upper/lower, front/back, top/bottom)
 

Other Information

  Supervisor of Activity  
  Phone Number  
* Person filling out this form  
* Phone Number  

 


NOTE: THIS REPORT DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY BY WESTMINSTER COLLEGE. 

If you have any questions, please contact:
Margaret Larsen
Gore Building, Room 213
801.832.2657
Fax: 801.832.3124