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MCC Police Department - Report of Injury Form
Home
Police
MCC Police Department - Report of Injury Form
MCC Police Department - Report of Injury Form
MCC Police Department - Report of Injury Form
Please fill out the form below and submit it:
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.)
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