VICTOR VALLEY COLLEGE STUDENT REPORT OF OCCUPATIONAL INJURY OR ILLNESS
REPORT ALL INJURIES TO YOUR INSTRUCTOR IMMEDIATELY
COMPLETE THIS FORM & BRING TO HUMAN RESOURCES WITHIN 24 HOURS OF INJURY/ILLNESS ONSET
PRINT NAME:
__________________________________________
HOME ADDRESS: __________________________________________
City/St/Zip
____________________________,CA ___________
mailing if different →__________________________________________
JOB TITLE:
__________________________________________
CLASS NAME: _____________________________________________
SOCIAL SECURITY - LAST 4 # ___________________
BIRTHDATE:
_______________________________
HOME PHONE: _______________________________
CELL & WORK PH: _____________________________
INSTRUCTOR: ________________________________
BUILDING NO./NAME:_________________________
DATE OF INJURY/ILLNESS:__________TIME:_____ AM PM
1) DID INCIDENT OCCUR ON DISTRICT PREMISES:
□YES □ NO
CLASS TIME BEGAN: _____ AM PM
WHERE DID IT OCCUR: __________________________
2) NATURE OF INJURY/ILLNESS – describe: twisted, struck, fell… & body part affected – example- right/left arm, swollen,
etc.
_____________________________________________________________________________________________________
3) What were you doing when injured? Specify activity and identify tools, equipment or material, if any, you were using.
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
4) What type of safety equipment, if any, is required for this activity?____________________________________________
5) Were you following prescribed safety procedures, including use of safety equipment?
□
□YES
□ NO
□
6) Have you ever been treated for a similar injury/illness?
YES
NO
IF YES, what date?______________
Name and address of treating physician at that time:_____________________________________________________
7) Name(s) of any witnesses to this particular incident:________________________________________________________
8) What do you recommend for preventing this type of injury? (State specific preventive measures):
_____________________________________________________________________________________________________
DO YOU REQUIRE OR DESIRE MEDICAL ATTENTION AT THIS TIME?
□ YES If so, you must request a Medical Service Order from Human Resources prior to obtaining medical service.
□ I already received emergency medical treatment (provide doctor’s report) (or if there has been an injury-reporting delay).
□ NO If not, please initial here: ___________ NOTE: Medical treatment may be requested at a later date but you will need
a Medical Services Order form from Human Resources BEFORE obtaining medical services.
I declare under penalty of perjury that the foregoing is true and correct and that I have received current information regarding
my benefits (attached pamphlet).
Signature of Employee: ___________________________________________ Date report completed: ____________________
HUMAN RESOURCES USE ONLY:
Date Report Received________ Date Form or Email to Supervisor:_________
10/21/2014
□ NO □YES
File only, no action □
PROVIDED DWC-1