ࡱ> ~} x"bjbj "zl<<<<<<<p |r p%R ZZZrrND$#######$% ' $<(rr(( $H <<Zr$H H H (<Z<r#H (#H H !<<!ZF pVp j!!$0%!(H (!H Pb<<<<Vigo County School Corporation INCIDENT INVESTIGATION REPORT E-Mail Form to  HYPERLINK "mailto:rls2@vigoschools.org" rls2@vigoschools.org and  HYPERLINK "mailto:brk@vigoschools.org" brk@vigoschools.org within 24 hours to the Risk Management Office. Call 462-4205 For Information Todays Date Time  FORMTEXT  DATE 8/10/20068/10/2006  FORMTEXT  TIME 9:51 AM9:51 AM Name of Preparer  FORMTEXT       Title  FORMTEXT       Phone  FORMTEXT        An incident is an unintended event generally caused by and unsafe act or unsafe condition or a combination of the two. Each incident, regardless of whether it results in an injury, illness, property damage or near incident, must be investigated to seek the cause and to take proper corrective actions to prevent reoccurrence. The purpose of this report is to gain facts, not place blame. The report is not considered complete until all affected sections are filled and the Risk Manager has signed off. Please input all information in the gray boxes below and the section above. Type of ReportSchool or LocationDate of OccurrenceTime of OccurrenceDate Reported FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN  FORMTEXT       FORMTEXT       FORMTEXT      Name of Injured or InvolvedAddressDaytime Phone   FORMTEXT       FORMTEXT       FORMTEXT      Student Section if applicableTeacher  FORMTEXT      Students Age  FORMTEXT      Male  FORMCHECKBOX  Female  FORMCHECKBOX Grade  FORMTEXT      Employee Section if applicableDate of Birth  FORMTEXT      Male  FORMCHECKBOX  Female FORMCHECKBOX  Marital Status  FORMDROPDOWN Occupation/Job Title  FORMTEXT      Date Hired  FORMTEXT      Hours/ Day  FORMTEXT   Days/ Week  FORMTEXT   Average Weekly Wage  FORMTEXT      Pay Frequency  FORMDROPDOWN Time Workday Began  FORMTEXT       Supervisor  FORMTEXT       Accident-Incident InformationLocation  FORMDROPDOWN  Type of Injury  FORMDROPDOWN  Body Part(s) Affected  FORMDROPDOWN   FORMDROPDOWN Response Information  FORMCHECKBOX  First Aid Provided Provided by:  FORMTEXT      Type of Occurrence  FORMCHECKBOX  Injury  FORMCHECKBOX  Illness  FORMCHECKBOX  Property Damage FORMCHECKBOX  Medical Services (Ambulance-EMT) Time of call:  FORMTEXT       by: FORMTEXT        FORMCHECKBOX  School Nurse Notified Time of call:  FORMTEXT       by: FORMTEXT        FORMCHECKBOX  Parent Guardian Notified Time of call:  FORMTEXT       by: FORMTEXT      Initial Treatment  FORMTEXT       Name of Parent or Guardian Notified:  FORMTEXT      Phone Number Called:  FORMTEXT      Describe the nature of the Injury, Illness, Exposure or Incident. Include how did the Injury, Illness, Exposure or Incident Occur? Provide all details so that anyone reading this can understand exactly what happened. This is very important. FORMTEXT      Additional Information  FORMTEXT       Witness Information1Name  FORMTEXT       Address  FORMTEXT       Phone  FORMTEXT       Other Info  FORMTEXT      2Name  FORMTEXT       Address  FORMTEXT       Phone  FORMTEXT       Other Info  FORMTEXT      Injured person released to:  FORMCHECKBOX Self  FORMCHECKBOX  Home  FORMCHECKBOX  Class  FORMCHECKBOX  Physician  FORMCHECKBOX  Hospital  FORMCHECKBOX  Other  FORMTEXT      Type of Evidence Collected:  FORMTEXT      Risk Management Department Section Name of Initial Physician  FORMTEXT        Review List  FORMCHECKBOX  Safety Training History  FORMCHECKBOX  Accident-Incident History  FORMCHECKBOX  OSHA 300 Recordable? 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