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ACCIDENTAL INJURY REPORT SEATTLE COMMUNITY COLLEGE DISTRICT VI CAMPUS SECURITY DEPARTMENT ACCIDENTAL INJURY REPORT South Seattle Community College | 6000 16th Ave SW Seattle WA 98106 | (206) 763-5157 C O N F I D E N T I AL I N F O RM AT I O N – N O U N AU T H O R I Z E D D I S C L O S U RE I N J U R E D P E R S O N NAME: (Last, First, M.I.): ADDRESS: (Local)

Social Security No:

AGE: SEX: CLASSIFICATION: TITLE OR STATUS: (Machinists, Student | Employee | Visitor Salesman, etc) SCHOOL OR DEPARTMENT: DATE OF OCCURRENCE: TIME OF DAY:

A C C I D E N T EXACT LOCATION OF ACCIDENT: NAME OF SUPERVISOR:

AREA OF OCCURRENCE:  Auditorium  Corridor, hallway  Student Center  Parking Lot  Bathroom, shower  Dressing or locker room  Laboratory  Other:  Cafeteria Kitchen  Grounds  Shop Area  Classroom, study room  Gymnasium  Stairs, ramps DETAILS OF ACCIDENT (Describe fully events, actions, and conditions; including environmental, emotional, and physical factors which contributed to the injury.

ACTION TO PREVENT SIMILAR ACCIDENTS (Indicate if taken or recommended):

WITNESS (Name, Address):

SCHOOL INSURANCE: Yes | (NO)

I N J U R Y

C O N F I D E N TI A L I N F O R M A T I O N – N O U N A U T H O R I Z E D D I S C L O SU R E C A M P U S S E C U R I TY D E P A R T M EN T I N C I D EN T R E P O R T South Seattle Community College | 6000 16th Ave SW Seattle WA 98106 NATURE OF INJURY  Amputation  Dermatitis, infection  Heat exhaustion, Sunstroke  Shock, electrical  Bruise, contusion  Dislocation  Inhalation- dust, fumes,  Shock, fainting gases  Burn, scald  Exposure, Frostbite  Internal injury  Sprains, strains  Concussion  Fracture  Poisoning, internal  Suffocation, drowning, strangulation  Cuts, open wounds  Foreign body  Rupture, hernia  Other, Specify PART OF BODY INJURED (Indicate right or left)  Generalized  Neck  Shoulder  Hip  Skull or scalp  Spine  Upper arm  Thigh  Eye  Chest  Elbow  Knee left  Nose  Abdomen  Forearm  Lower leg  Mouth  Back  Wrist  Ankle right  Jaw  Pelvis  Hand right thumb  Foot  Other Head  Other Trunk  Finger  Toe  Other, specify

T R E A T M E N T ESTIMATE OF SEVERITY EMERGENCY CARE GIVEN BY: (Name and address)  Minor  First Aid  Serious  Private Physician  Critical  Health Center  Fatal  Hospital, specify: transported to Virginia Mason WILL INJURY CAUSE ABSENCE FROM WORK OR IF SO, HOW LONG? CLASSES?

PATIENT STATUS This report prepared by (Signature) Date:  Non Patient  Out Patient Title or Status Department/Division SECURITY  Hospitalized CAMPUS SECURITY OFFICER

MEDICAL EMERGENCIES

1. For minor injuries or illness, report to your campus Safety and Security Office - See phone number listed at upper right. 2. If the person is seriously injured, do not move them unless there is a life-threatening danger (e.g., falling debris, fire, explosion) 3. In a life-threatening emergency, immediately dial 911, and request medical aid.  State the nature of the problem  Give your address and location in the building  Calmly and carefully provide the information requested by the 911 operator.  Do not hang up until told to do so. 4. When you complete the 911 call, immediately notify the campus Department of Safety and Security, see phone number listed at upper right, as they will need to meet the medical unit and guide them to the scene.  State the nature of the problem, the location and that you have already notified 911.  Provide as much information as possible about the illness or injury. 5. Let the victim know help is on the way and keep them as calm and comfortable as possible. If you are first aid trained and feel it is needed, administer first aid. Keep a list of your first aid and CPR certified staff and location of your first aid kit.

6. Remain with the victim until Safety/Security or emergency crews arrive.

Victim should be asked to complete and submit an accident report with the Department of Safety and Security. See ACCIDENT REPORTS/PREVENTION PLANS

C O N F I D E N TI A L I N F O R M A T I O N – N O U N A U T H O R I Z E D D I S C L O SU R E C A M P U S S E C U R I TY D E P A R T M EN T I N C I D EN T R E P O R T South Seattle Community College | 6000 16th Ave SW Seattle WA 98106 ACCIDENT REPORTS/PREVENTION PLANS

Reports: Any student, staff or visitor injured on campus must submit an accident report as soon as possible, regardless of the severity of the injury. This may be done at the campus Department of Safety and Security - See phone number listed at upper right.

Accident: Applies to any personal injury. Accident reports are not required for illness on campus unless injuries result (e.g., a seizure causes the person to fall and strike an object).

Student/visitors: If the injury occurs to a student or visitor to the campus, an accident report should be submitted, but any medical expenses incurred must be paid for by the individual or their personal health insurance.

Employee: An accident occurring to an employee or a work study student during their working hours is covered by Washington State Industrial Insurance. An injured employee who requires medical attention must advise the physician or hospital of this coverage immediately so they may initiate an industrial insurance form. The health care provider will then forward this form to the employer. The campus Department of Safety and Security receives and completes these reports on behalf of the college and forwards the finalized copies to the Department of Labor and Industries in Olympia. Any verbal or written communications received by a divisional office with regards to an injured employee(s) should be immediately submitted to the Department of Safety and Security.

Accident Prevention Policy: SCCD believes in the dignity and importance of the individual employee and his or her right to derive personal satisfaction from their job. The prevention of occupational injuries and illnesses is given top priority at all times.

As per WAC 296-24-040, a college accident prevention program has been developed that emphasizes the integration of safety and health measures into each job task so that safety/health and job performance become inseparable. This will be accomplished through the cooperative efforts of managers, supervisors, and employees.

By accepting mutual responsibility to operate safely, we will contribute to the well being of all personnel.

C O N F I D E N TI A L I N F O R M A T I O N – N O U N A U T H O R I Z E D D I S C L O SU R E C A M P U S S E C U R I TY D E P A R T M EN T I N C I D EN T R E P O R T South Seattle Community College | 6000 16th Ave SW Seattle WA 98106