INCIDENT REPORTING FORM FOR VOCATIONAL-TECHNICAL EDUCATION PROGRAMS AND STRUCTURED LEARNING EXPERIENCES County: CO: District: DIST School: I. INCIDENT INFORMATION ll. TYPE OF VOCATIONAL-TECHNICAL EDUCATION PROGRAM/STRUCTURED LEARNING EXPERIENCES A. PERSON A. CAREER CLUSTER (Mark only one) Last Name First Name Agriculture & Natural Resources Constuction Arts & Communications Services B. Male Female Business & Administrative Education & Training Srvs. Financial Services C. Student Staff Other (specify) Public Administration/Gov't Srvs. Health Services Hospitality & Tourism Note: Staff m ust also be reported on the OSHA 300 Human Services Information Technology Srvs. Legal and Protective Services D. INCIDENT TOOK PLACE Wholesale/Retail Sales and Science Research & Tech. Srvs. Manufacturing At School At Job Site Travel to/from Job Site Logistics,Transportation, & Distribution Services E. INJURED PERSON SENT TO DOCTOR HOSPITAL B. CIP CODE/PROGRAM C. ENROLLMENT IN CIP CODE F. GRADE K-6 7 8 9 10 11 12 Adult D. STRUCTURED LEARNING EXPERIENCE (Mark only one) G. AGE Cooperative Education Service Vocational Student H. Did incident occur off school property? Yes No Volunteer Activity Learning Organization Activity (If answer to H is "Yes," answer questions I, J, K and L) I. Actual hours in school on day of injury Job Shadow ing Internship Apprenticeship J. Actual hours at w ork on day of injury School-Based Enterprise Community Service WECEP K. Type of Business Business Location Other (specify) L. Student Job Title Yes No E. Did incident involve a student with an Individualized Education Program (IEP)? III. DESCRIPTION OF INJURY) A. PART OF BODY INJURED (Mark all that apply) IV. Date and Time of Incident Abdomen Buttocks Elbow Foot Leg Ribs Teeth Urinary/Genital Ankle Chest Eye Hand Lungs Scalp Throat Month Day Year Hour Min AM/PM V. Narrative: Briefly describe Incident, include surrounding Arm Collar-Bone Face Head Mouth Stomach Wrist Nose conditions,actions, tools and equipment involved Back Ear Finger Knee Neck Other (specify) B. APPARENT NATURE OF INJURY (Mark all that apply) Abrasion Bite Concussion Fracture Scalding Splinter Sprain Sting Amputation Bruise / Bump Cut / Laceration Poisoning Scratch Other (specify) Asphyxiation Burn Dislocation Puncture Shock VI. Corrective Action Taken: Describe w hat measures have been taken to correct the conditions leading to incident C. CAUSE OF INJURY (Mark all that apply) Struck By Rubbed or Abraded Horseplay Caught In, Under, or Betw een Contact w ith Temperature Struck Contact w ith Caustic, Repetitive Inhaled Toxic or Noxious Against Motion Substance Overexertion Toxic, or Noxious VII. Report Com pleted By: Contact w ith Electric Current Fall from Elevation Fall from Same Level Other (specify) Signature & Title: D. DEGREE OF INJURY AT TIME OF AWARENESS: Signature of Principal (Date): Non-disabling Temporary Disability Permanent Death Signature of Safety & Health Designee (Date): Yes No E. PERSONAL PROTECTIVE EQUIPMENT Was personal protective equipment worn at the time of the incident? What type of protective equipment was used?
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