Fill and Sign the Snhu Transcript Form

Revised 6/11 Date: Time: a.m./p.m. Activity: Accident Report This form must be filled out for any accident occurring in the Heskett Center Name of injured: Phone #: Address: Campus ID#: Date of birth: Male Status of injured: (please circle one) Female Student Guardian's name ( if under 18 ): Faculty Staff Guest Other: Description of Accident: Accident Location: ( please circle all that apply ) Heskett Center: Gymnasium A BCD E Track Bleacher Area Climbing Wall Sand Pit Pole Vault Area Dance Studio A B Natatorium Swimming Pool Diving Well Outdoor Terrace Locker Room Lobby Main Over look of pool Upper Nature of Injury: ( please circle all that apply ) Head Scalp Eye: L R Nose Mouth Neck Back Hip: L R Other body part ( specify ): History of prior injury (if any ): Type of shoe worn ( if applicable ): Racquetball Courts Squash Court Cardio Room Circuit Room Combatives Gymnastics Multi-purpose Rm (143) Weight Room Class Room # Shoulder: L R Abdomen Arm: L R Elbow: L R Outdoor Areas: Tennis Courts Cessna Stadium Softball Complex IM Fields (Heskett) IM Fields (Metroplex) Bombardier Learjet Indoor BB Complex Other: Hand: L R Wrist: L R Finger: Leg: L R Knee: L R Ankle: L R Foot: L R Toe: Action taken/ assistance given: Did Injured party refuse care? Was EMS called? Yes Yes No No Initialed by injured If so, at what time? EMS arrival time: If not, why not? Injured person was taken to ( location ): By ( individual transporting ): Witness’s Name: Phone #: Address: Campus ID#: What you witnessed: Witness’s signature: Date: I have been advised as to the risks of continuing participation in the activity where this accident occurred and I have been further advised of the benefit of seeking medical advice. Nevertheless, it is my opinion that I am able to continue participation and it is my sole and individual decision to do so. In consideration of the opportunity to continue with the activity, I waive and release Wichita State University, its employees and its representatives, from any and all claims for injuries or damages that may result from my decision to continue participation in the activity or the negligence of Wichita State University, its employees and/or representatives. Injured person’s signature: Date: Employees: Please answer the following questions and return this form to the Director before the end of the shift. If Yes, What equipment (PPE) were you wearing: If yes, provide the name of that person or persons and activate the Post Exposure Plan immediately. Name of Employee (please print) Name of Employee (please print) I verify that the information on this report is true and accurate to the best of my knowledge. Employee Signature: Print: Date: I have read the information above with care and agree that it is both accurate and complete. Injured person’s signature: Print: Date: