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)

Did the incident occur inside, outside, or in a semi enclosed environment?

Indoor (Example: in the classroom with one or more doors leading outside but no operable windows leading outside)Indoor (Example: in the classroom with no open doors leading outside but one or more operable windows leading outside)Indoor (Example: in the classroom with neither doors nor operable windows leading outside)Outdoor (Example: in field, at outdoor worksite)Semi enclosed (Example: in workshop with open garage doors, parking structures like mall parking lots)N/A or Unknown

12)

If outdoor/semi enclosed: Was there any weather (high/hot or low/cold temperature either outside or indoors, rain, snow, slippery walkways) during (at or around) the time of day of the reported incident?

13)

Type of business where injury occurred (if applicable)

*14)

Student co-op/SLE job title

*15)

Injured person sent to

Doctor

Hospital

*17)

Age of injured person

*20)

Did the injured person miss any time at school due to this incident?

YesNoI don't know

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