MCC Police Department - Report of Injury Form

MCC Police Badge

Please fill out the following form and submit it.

If you have additional space, please use a Word document and send it via email to If you would like a copy of filled out form, print by using Control + P to print or Save As and save a copy to your device before hitting the Submit button.


Supervisor was notified at time of injury?:

(Campus, Building, area, ...)
Initial Treatment Sought:

(please include activity, tools, materials, and equipment using at the time injury occurred)
(My signature and/or submission verifies that this is a true and correct statement of events.)
Enter security code:
 Security code