Accident Report Form

All accidents should be reported. Please notify the Department of Dance at 614 292-7977 for immediate assistance. Complete the form below for submission to the Academic Program Coordinator as soon as possible following the accident.

This form is for documentation purposes only and is not shared outside the Department of Dance. Submission of this form is not intended for evaluation or medical diagnosis. Students are encouraged to consult with their medical provider.

Contact Information

Name of Injured Student: *

OSU E-mail: *

College: *

Major Program: *

Status: *

Accident Information

Date of Injury: *

Month

Day

Year

Time of Injury: *

Hour

Minute

Name of Instructor: *

The Accident Occured: *

In class

Outside class

Location: *

Classroom: *

Nature of Accident: *

Please be as specific as possible.

Care/Assistance: *

Describe the care/assistance given immediately following the accident (e.g. ice applied, wrapped, assisted to stand; called: Department [614 292-7977], emergency contact, 911, etc.)

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Accident Report Form

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