Metropolitan Community College

First Name:

M.I.:

Last Name:

MCC ID#:

Status:

Employee
Student

Date of Injury:

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:

MCC Police Department - Report of Injury Form

Police