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CVE Injury Form
Please use this form to report
ALL
student related injuries or "near miss" events (which could have caused an injury) - no matter how minor. This will help us to gather data on student behavior.
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* Indicates required question
Name of CVE Member
*
Your answer
Name of School Site
*
Your answer
Who inflicted the injury?
Choose
Gen Ed student
RSP student
SDC student
Date of Incident
*
MM
/
DD
/
YYYY
Severity of Injury
*
Minor
Moderate
Serious (ex. had to go to Urgent Care or the Emergency Room)
Severe (ex. had to take time off work for injury)
Injury Region
*
Head
Neck
Face
Chest
Abdomen
Arm(s)
Leg(s)
Required
Brief description of the incident
*Don't forget to report ALL injuries to admin as well!
*
Your answer
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