Student Injury Report Form
Please use this form to report a student injury on campus or at a College sanctioned program/event. The form will be reviewed within 24 hours. If additional information is needed someone will contact you. 

Injury reports for employees are reported to Human Resources at hr@meca.edu.
Sign in to Google to save your progress. Learn more
Email *
Your Full Name (First & Last) and MECA*D connection (e.g., staff, student, faculty, vendor) *
Individual reporting the injury
Individual(s) Injured Name (First & Last) and MECA&D connection (e.g., staff, faculty, student, vendor) *
Individual(s) injured 
Date of Injury *
MM
/
DD
/
YYYY
Time of Injury *
Please include a.m. or p.m.
Time
:
Building or Location *
Required
Narrative *
Provide a detailed description of the injury including: when and where it occurred, how you became aware of the situation, who was involved, was there EMTs called, and etc. Remember to be objective, not draw conclusions, and report only your experience (i.e. what you saw and heard).
Signature and Certification *
By checking the box below, I hereby believe this report to be true and accurate. Individual(s) making false injury reports may be sanctioned through the Student Code of Responsibility or Human Resources.
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Maine College of Art.

Does this form look suspicious? Report

Google Forms