MCC Police Department - Report of Injury Form

First name M.I. (middle initial) Last name MCC ID# Status Employee Student Date of Injury (month/day/year) Time of Injury Supervisor was notified at time of injury? Yes No Where did the injury occur? (Campus, Building, area, ...) Time started work Part of body affected Initial Treatment Sought No Medical Treatment Required First Aid by Employer Minor Clinic/Hospital Emergency Room Hospitalized Overnight Hospitalized over 24 hours Other Treatment Explain Time Left Work Name of Physician or Health Care Provider Explain how the injury occurred (please include activity, tools, materials, and equipment using at the time injury occurred) Signed By (My signature and/or submission verifies that this is a true and correct statement of events.) reCAPTCHA