Hartford School District Faculty + Staff Accident Report Form
What is your name?
*
First Name
Last Name
What is your email address?
*
example@example.com
What is your mailing address?
What is your home telephone number?
What gender to you identify as?
What is your date of birth?
What is your job title?
What school, program, or department do you work at in the Hartford School District?
What was your date of hire?
What is the date when the accident occurred?
What is the date when you reported the accident to your employer?
What time do you start work each day?
What time did the accident occur?
What is the address of where the accident occurred?
Did the accident occur on Hartford School District property?
Yes
No
Where is the exact location that the accident occurred (classroom/playground/hall, etc)?
Was a machine or tool involved in the accident?
Yes
No
Other
If there was a machine or tool involved in the accident, was it defective?
Yes
No
Have you missed work because of the accident?
Yes
No
If you missed work because of the accident, what date did you return to work?
Does the injury involve the back, knee, or shoulder?
Yes
No
If the injury did not involve the back, knee, or shoulder, what part(s) of the body were injured?
Please provide a detailed description of the accident/injury.
Have you sought medical treatment for the injury related to this accident?
Yes
No
Were you seen in the Emergency Room?
Yes
No
Were you hospitalized overnight?
Yes
No
If you sought medical treatment, please provide the physician's name, the name of the practice the physician works in, and the mailing address of the practice.
Who is your building administrator or program coordinator?
*
Sara Rose
Patrick Peters
Doug Kussius
Erica Rogstad
Vincent Mascola
Amy Molina
Cody Tancreti
Heather Obar
Erika Schneider
Caty Sutton
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