Incident Reporting Form

INCIDENT REPORTING FORM

FOR

CAREER AND TECHNICAL EDUCATION PROGRAMS

AND

STRUCTURED LEARNING EXPERIENCES (SLE)

Revised Version - August 2011

Instructions: Please complete and submit this report within five working days of the occurrence of the injury or illness. Injury or illness must result in treatment by a licensed physician for it to be reportable. For further guidance on filling out this form, please consult the New Jersey Department of Education (NJDOE) Incident Reporting Guide.

1A. Demographic Information

*1)

County (FIPS Code)

Voc-tech School District

School District (If you are from a voc-tech district, per response to question #2, please skip to question #4.)

*4)

School Name

IB. Incident Information

*5)

Gender of injured person

Male

Female

Ethnicity of injured person?

Hispanic or LatinoNot Hispanic or Latino

*8)

Injured person was a: (Note: Staff must also be reported on the OSHA 300)

Student

Staff

Other (please specify)

Other:

*9)

Did incident occur off school property?

Yes

*10)

Where incident took place

At school

At co-op/SLE site

Travel to/from co-op/SLE site

11)

Type of business where injury occurred (if applicable)

*12)

Student co-op/SLE job title

*13)

Injured person sent to

Doctor

Hospital

*15)

Age of injured person

II. Type of Career and Technical Education Program, Cooperative Education Experience, or Structured Learning Experiences

*18)

Career cluster

*19)

Cooperative Education Experience/Structured Learning Experience

Other:

*20)

Did incident involve a student with an Individualized Education Program (IEP)?

Yes

III. Description of Injury

*24)

Degree of injury at time of awareness

Non-disabling

Temporary Disability

Permanent Disability

Death

*25)

Was Personal Protective Equipment worn at the time of the incident?

Yes

*26)

What type of Personal Protective Equipment was worn?

IV. Date and Time of Incident

*27)

Date of incident (MM/DD/YYYY)

*28)

Time of incident (HH:MM AM/PM)

V. Narrative

*29)

Briefly describe the incident, including surrounding conditions, actions, tools and equipment involved

(1000 characters remaining)

VI. Corrective Action Taken

*30)

Describe what measures have been taken to correct the conditions leading to the incident. It is assumed that every incident can be prevented. Not applicable (N/A) or blank is not an acceptable response. Possible corrective actions include providing education, repairing faulty equipment, using proper personal protective equipment, securing the environment, etc.

(1000 characters remaining)

VII. Report Completed By

*31)

Name of person completing this report

*32)

Title of person completing this report

*33)

Date of report submission (MM/DD/YYYY)

Note: If you would like a copy of this report for your records, then click on the print option below

Your unique Respondent ID# is: 8794525

(Print this page)

Continue ONLY when finished. You will be unable to return or change your answers.