Accident Report (Other Than Motor Vehicle)

THE FOLLOWING INFORMATION SHOULD BE SUBMITTED BY THE INSTRUCTOR, SUPERVISOR OR OTHER UNIVERSITY EMPLOYEE HAVING KNOWLEDGE OF AN ACCIDENT WHEN EVER A STUDENT, VENDOR OR CAMPUS VISITOR IS INJURED ON UNIVERSITY PROPERTY OR DURING A UNIVERSITY SPONSORED ACTIVITY AND/OR IF PERSONAL PROPERTY DAMAGE IS INCURRED. ALL INJURIES, OTHER THAN FIRST AID, SHOULD BE REPORTED. PLEASE REPORT IMMEDIATELY IF A SERIOUS INJURY OCCURRS OR WITHIN 48 HOURS FOR OTHERS. IF MORE SPACE IS NEEDED, PLEASE PROVIDE ADDITIONAL PAGES. EH&S PHONE: EXT. 2401.

Return to Environmental Heath, Safety & Risk Management/Mail Drop 8284
THE FOLLOWING INFORMATION SHOULD BE SUBMITTED BY THE INSTRUCTOR, SUPERVISOR OR OTHER UNIVERSITY EMPLOYEE HAVING KNOWLEDGE OF AN ACCIDENT WHEN EVER A STUDENT, VENDOR OR CAMPUS VISITOR IS INJURED ON UNIVERSITY PROPERTY OR DURING A UNIVERSITY SPONSORED ACTIVITY AND/OR IF PERSONAL PROPERTY DAMAGE IS INCURRED. ALL INJURIES, OTHER THAN FIRST AID, SHOULD BE REPORTED. PLEASE REPORT IMMEDIATELY IF A SERIOUS INJURY OCCURRS OR WITHIN 48 HOURS FOR OTHERS. IF MORE SPACE IS NEEDED, PLEASE PROVIDE ADDITIONAL PAGES. EH&S PHONE: EXT. 2401.
Not for Employee Injuries (This is a Confidential, Internal Report)

Name of Injured Party (Last, First MI.)		CSUN ID#:	Date:

Address:		Phone:	Email:

Cause of Accident/Injury: (Why did it happen?)

Part of body injured (List each body part):

Location of the accident (Be Specific): CSUN Campus Map

Medical Insurance? No Yes Unknown - If Yes, Detail:
Campus Police Responded? No Yes If Yes, Name of Officer:
Injured Treated At or By: Given First Aid Student Health Center Hospital/Doctor
Ambulance None Unknown
Description of University or Personal Property Involved:


I. University Person Reporting:
Name/Department:		Home Phone:
		Campus Phone:
II. Witnesses:
1. Print Name Clearly (Last, First, MI.)
Full Address:
Work Phone:	Home Phone:
2. Print Name Clearly (Last, First, MI.)
Full Address:
Work Phone:	Home Phone:

3. Print Name Clearly (Last, First, MI.)
Full Address:
Work Phone:	Home Phone:

III. Follow Up:
Corrective ActionTaken or Recommended: (list on seperate page if necessary)

Preparer of Accident Report: (Print Name)

_____________________________________		Today's Date:
Signature:

Please PRINT this Form Double-Sided