Report • CampusOptics

Vehicle Accident

If this accident involved a college vehicle or college rental vehicle, you must also complete Appendix A - Automobile Liability Loss Report.

Send Accident/Injury Reporting Form to Environmental Health and Safety (EH&S) as soon as possible and no later than 24 hours of injury/accident.

Fax: (520) 206-2771

Campus Mail: MS-1805

E-mail: ehs-info.pima.edu

Phone: (520) 206-2766

Clinic Information for Employees

The employee must use a Concentra medical provider for their first doctor's appointment. Clinics that are familiar with the College and the worker's compensation process are listed below.

Concentra

2945 W. Ina Rd, Suite 103 - (520) 289-8018

2301 N. Forbes, Suite 111 - (520) 628-4340

2005 W. Ruthrauff Rd - (520) 293-7250

4600 S. Park Ave. Suite 5 - (520) 889-9574

7119 E. Broadway Blvd - (520) 881-0050

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

Loading…

Sections A: General Information - (To be filled out by injured/person involved)

Name of person involved or injured

Incident Date

Time of Incident

Who is filling out this form?* Required

Affiliation

Department

Position

Phone

Section B: Description of the Event - (To be filled out by injured/person involved)

What happened? (Description of the event and how it occurred, e.g.airs while carrying boxes, burned finger while soldering)

Actions taken to control effects of incident(e.g. used fire extinguishers, administered first aid)

Describe Injuries: (Include parts of the body, e.g. left elbow, neck)

What factors contributed to the event?(e.g. faulty equipment, wet conditions)

Section C: Preventative Measures - (To be filled out by injured/person involved)

What can be done to avoid this situation in the future?

Other individuals involved and/or observed incident

Did/Will you see a doctor or other healthcare professional for this injury?

Signature* Required

Add Supporting Documents