UTMB Student Accident and Injury Report Form

DO NOT USE THIS FORM TO REPORT EXPOSURES TO BLOODBORNE PATHOGENS

Name: ______________________________________ Student ID #: ____________________ Last First MI Address: ______________________________________________________________________ Home phone #: _____________________ Pager or cell phone #: ____________________ School: ______________________ Program: __________________ Date of injury: ______________ Time of injury: ________ AM PM Injury location: _______________________________________________________________ Building Floor Room Number Brief description of what happened: __________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________

Body Part Effected X Mark Appropriately X Mark Appropriately R L Head Eye Face Shoulder Neck Arm Chest Hand Stomach Finger Back (lower) Leg Back (upper) Knee Ankle Foot Toe

Item or equipment involved in accident or injury: ___________________________________ Witnesses (name & title): ________________________________________________________ INFORMATION RELEASE By signing this report form, I understand that I am giving my authorization to UTMB and Student Wellness’ designated medical records custodians or database custodians to use and/or disclose my protected health information for the purpose of reviewing the accident/injury reported on this form for determining necessity of medical care and possible reimbursement by third party payers. Signature of student: ______________________________________ Date: ______________________ Return completed form to Student Wellness route 0169. Call 409-747-9320 with any questions.