INCIDENT REPORTING FORM FOR VOCATIONAL-TECHNICAL EDUCATION PROGRAMS by nrk14057

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									                      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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