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Police
MCC Police Department - Report of Injury Form
About MCC
About MCC
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Careers at MCC
MCC Police
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News Center
Equity & Inclusion
Explore MCC
Explore Careers
GED & ESL
College Catalog
Life at MCC
Student Organizations
Intramural & Recreational Activities
Student Leadership Opportunities
Degrees & Certificates
Business
Community & Human Services
Creative Arts & Design
Health Professions
Information Technology
Skilled Trades & Technical Sciences
Transfer
Transfer Center
Transfer Partners
Getting Started
How To Apply
180 RAP Students
International Students
Military-Connected Students
Returning Students
Transfer Students
High School Students
Tuition & Financial Aid
Tuition
Financial Aid
Scholarships
New Price Calculator
Payment Options
Academic Calendar
Student Resources
Academic Support & Tutoring
Learning & Tutoring Center
Writing Center
MCC Bookstores
Campus Dining
Career Experiences
Disability Support Services
Intercultural Activities
MCC Student Orientation
Records & Transcripts
Student Advocacy
Testing Services
Transfer Center
Transportation Options
Pass to Class
Carpooling
TRIO
Community & Business
Community Events
Community & Workforce Education
Community Education
Workforce Education
Libraries & Galleries
MCC Libraries
MCC Galleries
Sage Student Bistro
MCC Police Department - Report of Injury Form
Please fill out the following form and submit it.
First Name:
M.I.:
Last Name:
MCC ID#:
Status:
Employee
Student
Date of Injury:
Calendar
Today
Time of Injury:
Supervisor was notified at time of injury?:
Yes
No
Where did the injury occur?:
(Campus, Building, area, ...)
Time started work:
Part of body affected:
Initial Treatment Sought:
No Medical Treatment Required
First Aid by Employer
Minor Clinic/Hospital
Emergency Room
Hospitalized Overnight
Hospitalized over 24 hours
Other Treatment
Explain:
Time Left Work:
Name of Physician or Health Care Provider:
Explain how the Injury Occurred:
(please include activity, tools, materials, and equipment using at the time injury occurred)
Signed By:
(My signature and/or submission verifies that this is a true and correct statement of events.)
Security code:
Enter security code:
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MCC Police Department - Report of Injury Form
Request a Copy of a MCC Police Report