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Employee/Volunteer Accident Investigation Report
This is a CONFIDENTIAL REPORT for use by Rancho Santiago Community College District and its attorneys. No copies of this
report shall be furnished to anyone including employees or parents without permission from the office of Risk Management.
This report must be completed within 24 hours of an accident involving an injury to an employee/volunteer. Send completed reports to Risk
Management and keep one copy of this investigation at your location.
Part I – To Be Completed By Injured/Ill Employee/Volunteer
Employee ___ Volunteer ___ Student Employee ___
Name of Injured Person: ______________________________ Home Telephone: _______________________________
Home Address: _____________________________________ City: _________________________ Zip: ___________
Date of Birth: __________ Employee #: ________________ Work Location: Campus __________________________
Department: __________________ Job Title or Occupation: ____________________________
Average Hours worked per week: _____ Average hours worked per day: M ___ T ___ W ___ Th ___ Fr ___ Sa ___ Su ___
Employee’s Supervisor: _____________________________ Department Phone #: _____________
WHEN AND WHERE DID THIS HAPPEN?
Date of Injury: ___________ Time of Injury: ___________ Date Reported: __________ Time Reported: __________
Location of Injury (Campus) _______________________
Exact location of injury (Building, Room #) _________________________________________________________________
(If injury happened off-site indicate location, address, city and zip:) ______________________________________________
HOW DID THE INJURY OCCUR?
Describe what happened and what you were doing just prior to the injury. What tools or equipment were involved?
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
WHAT INJURIES RESULTED?
Type of injuries and body part(s) injured. Example: “Cut left pinky finger and hurt lower back”.
_________________________________________________________________________________________________
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Employee Signature Date
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