Student Accident Report Form

Academic Environmental Health & Safety
College of St. Benedict/St. John's University






This form should be filled out by the injured student and the supervisor.




Nature of Injury

Check all that apply.





















Part of Body Injured

Check all that Apply






















Description of Accident




The following questions should be answered by the accident victim.
Did the accident occur during class time?
Did the accident occur in the recommended work area?
Have you been given information concerning the safe use of the equipment/processes involved?
Have you been given a demonstration concerning the safe use of the equipment/processes involved?
Check PPE(s) worn at the time of the incident





Did you apply or receive first aid?

Did you go to the clinic/health center for treatment?