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Notify your course instructor by the end of the class where the injury/illness/near miss occurred.  \n2. Complete this form in its entirety, sign it and have your faculty advisor sign it.  \n3. Scan and email the signed form to [Risk.Management@tri-c.edu](Risk.Management@tri-c.edu) within one day of the injury/illness/near miss.  \nSECTION 1 – BASIC INFORMATION  \n\n| Student’s Name: | Faculty Advisor’s Name: |\n| --- | --- |\n| Student’s College I.D.: | Faculty Advisor’s Title: |\n| Date of Injury/Illness/Near-Miss: | Faculty Advisor’s Office Address: |\n| Address where Injury/\u003Cbr>Illness/Near-Miss occurred: | Department and Campus: |\n| Student’s Home Address: | Faculty Advisor’s Office Telephone Number: |\n| City, State, Zip: | Faculty Advisor’s Email: |\n| Home Phone Number: |  |\n| Witness Name(s): | Were you participating in a course or clinical experience?\u003Cbr>Yes No |\n| What action was taken (check all that apply):\u003Cbr>Went to Hospital Went to private doctor Went Home Returned to class Received first aid/self-treatment Refused any action | If you went to a hospital or private doctor, list the name and address of the treatment facility: |\n\nSECTION 2– Description of Injury/Illness/Near-Miss (use additional paper if needed)  \nIn your own words, describe how the injury/illness/near-miss occurred:  \nIn your own words, what object or substance directly caused the injury/illness/near miss:  \nSECTION 3 – Nature of Injury/Illness/Near-Miss and Body Part(s) Affected  \n\n| What body part(s) were injured? For, example,“left leg”. | What was the nature of the injury to the body part? For example,“cut” or “burn”. |\n| --- | --- |\n|  |  |\n\nSECTION 4 – Injury/Illness/Near-Miss Prevention Information  \nWhat could be done to reduce the possibility of a similar injury/illness/near-miss occurring in the future?  \nSECTION 5 – Signatures  \n\n| Student signature and date: | Faculty advisor signature and date: |\n| --- | --- |\n\n3/4/2021","cbCaib9Y43UJLP7y","https://ap.wps.com/l/cbCaib9Y43UJLP7y","pdf",136884,"English","# Instructions\n## Submission steps\n# Section 1 – Basic Information\n## Student and faculty advisor details\n## Witnesses and participation\n## Actions taken\n# Section 2 – Incident Description\n## How it occurred\n## Direct cause\n# Section 3 – Nature and Body Parts\n## Body parts affected\n## Nature of injury\n# Section 4 – Prevention Information\n## Recommendations to reduce recurrence\n# Section 5 – Signatures\n## Student and faculty advisor","[{\"question\":\"What incident types does the report cover?\",\"answer\":\"The form covers injury, illness, and near-miss events.\"},{\"question\":\"When and how should the signed report be submitted?\",\"answer\":\"Notify the course instructor by the end of the class and email a scanned, signed copy to Risk.Management@tri-c.edu within one day of the incident.\"},{\"question\":\"What information is required in Section 1?\",\"answer\":\"Section 1 collects student and faculty advisor details, incident date and location, department and campus, contact information, witness names, whether the student was participating in a course/clinical experience, and actions taken.\"}]","Cuyahoga Community College Student Incident Report - Form | PDF"]