Teen Court Injury Accident Report

Date of Report _________________ Date of Injury ______________

Injured Party ________________________________ Age ______

Title ______________________ ID Number ___________

Location ______________________ Department ________________

Date of Membership _______________ Time as member (months) ______

Time in this position (months) ____________

Date of Injury _____________________ Time of Injury ______

Exact Location _____________________________________________________

Names of Witnesses

_________________________________________________________________________________________________________________________________________________________________________________________________________________

Injury to:

[ ] Face or Head [ ] Legs [ ] Eyes [ ] Toes or Foot [ ] Body

[ ] Internal [ ] Arms [ ] Lungs [ ] Hands or Fingers

[ ] Other _______

Type of Injury:

[ ] Lacerations [ ] Amputation [ ] Strain or Sprain [ ] Burns [ ] Hernia

[ ] Foreign Body [ ] Fracture [ ] Skin [ ] Puncture [ ] Gas

[ ] Abrasion [ ] Other _______

Treatment:

[ ] First Aid [ ] Nurse [ ] Doctor's Care [ ] Serious [ ] Lost time [ ] Fatality

Remarks: Be specific (L or R arm, etc.) _____________________________________ ___________________________________________________________________ ___________________________________________________________________

Describe how member was injured: (What was member doing? What duty or task?) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

What happened that resulted in this injury? (Examples: slipped, fell, was struck) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

What factors do you believe contributed to this accident? (Consider methods, procedures, environment, tools, machines, equipment arrangements, instructions, rules, inherent hazards, skill, experience, materials, and other factors.) _________________________ ___________________________________________________________________ ___________________________________________________________________

How could such an accident have been prevented or avoided? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

The investigating Committee (People to be included in the accident investigation are listed below.)

1. Injured Member ______________________________________

2. Immediate Supervisor ___________________________________

3. Safety Committee person _________________________________

4. Safety Committee Investigator____________________________

5. Teen Court Coordinator (or Rep.) _______________________________

6. Witnesses ____________________________________________

7. Teen Court Master _______________________________

8. Teen Court Advisor______________________________

9.Administrator (or Rep) _______________________________

Note: Report to be completed by immediate supervisor and turned in to the Safety Committee no later than the end of the day following the injury. All lost time injuries or fatalities must be promptly reported.

Important: All fatalities or accidents resulting in five or more persons being hospitalized must be reported to the appropriate federal or state agency enforcing OSHA regulations within the time limits applicable.

PEOPLE TO BE INCLUDED IN ACCIDENT INVESTIGATIONS:

Near Miss/No Injury

The extent of the investigation will be left to the discretion of the administration.

Slight (First Aid)

Immediate Investigation

1. Injured Member

2. Immediate Supervisor

Nurse Case

Immediate Investigation

1. Injured Member

2. Immediate Supervisor

3. Safety Committee person

Doctor Case

Immediate Investigation

1. Injured Member

2. Immediate Supervisor

3. Safety Committee person

4. Teen Court Coordinatior

5. Teen Court Master

6. Witnesses

Final Investigation

1. Injured Member ______________________________________

2. Immediate Supervisor ___________________________________

3. Safety Committee person _________________________________

4. Safety Committee Investigator____________________________

5. Teen Court Coordinator (or Rep.) _______________________________

6. Witnesses ____________________________________________

7. Teen Court Master _______________________________

8. Teen Court Advisor______________________________

9.Administrator (or Rep) _______________________________

Click on Back Button to Exit or Go to The National Teen Courts of America Home Page