HTML Preview Nursing Incident page number 1.
MUSC College of Nursing, April 2015
MUSC College of Nursing
99 Jonathan Lucas Street MSC 160
Charleston, SC 29425
Incident Report
PART 1: Instructor Statement
STUDENT NAME:
DATE & TIME OF INCIDENT/INJURY:
LOCATION WHERE INCIDENT OCCURRED:
COURSE TITLE AND INSTRUCTOR NAME:
DESCRIPTION OF INCIDENT:
Student has declined medical treatment for the above injury/incident: ________ (instructor’s initials)
Completed and signed by:
Date:
INSTRUCTOR’S RESPONSIBILITY:
1. For SERIOUS OR EMERGENCY injuries/incidents in the classroom, skills lab or clinical setting send student to
Hospital ER or CALL 911.
2.
For ALL injuries/incidents:
Immediately notify the Program Director.
Complete Part 1, Instructor Statement, of the Incident Report. Give Part 2, Student Statement, to the
student to complete and return to you, even if treatment is declined.
Submit Part 1 and Part 2 to Gena Ryan, Compliance Officer by email to [email protected]
or deliver to Office
300-A. The student is required to go to Student Health Services at 30-A Bee Street, Charleston, SC 29425 within
24 hours of the incident or on the College's next regularly scheduled workday.