Central Piedmont Community College

CENTRAL PIEDMONT COMMUNITY COLLEGE

HEALTH SCIENCES

HEALTH & HUMAN SERVICES

MEDICAL CAREERS & COSEMETOLOGY

NURSING

NON-EXPOSURE OCCURRENCE REPORT FORM FOR STUDENTS

INSTRUCTIONS

(does not involve exposure to blood or body fluids)

INSTRUCTIONS

A. Report the occurrence, accident, injury immediately to the appropriate person(s) (Clinical Facility Preceptor,

CPCC Clinical Coordinator, Program Chair, Division Director, Environmental Health and Safety Officer, and

Security, if occurrence takes place on a CPCC campus). The phone number for the Environmental

Health and Safety office is: Aashima Rodkey (704) 330-6580 or Robert Patterson (704) 330-5492

B. Use this form for reporting student accident/injury/occurrence:

C. In describing the occurrence, indicate chronological order of the events at the time of the occurrence.

D. Any individual experiencing an accident/ injury will be advised to seek medical evaluation
immediately, if warranted.

E. CPCC’s Clinical Coordinator, Program Chair, and the Division Director will be responsible for evaluation
and follow-up of the occurrence in terms of the individual’s condition, safety precautions, status of equipment,
and action taken to correct the situation.

F. Should a non- exposure occurrence, accident, or injury take place at a facility that participates with CPCC for
student affiliations, please follow that facility’s protocol for reporting/documenting such occurrences.
However, a copy of the report should be given to the appropriate persons at CPCC.

G. Submit all reports to the Program Chair, Division Director, and Environmental Health and Safety Office
no later than 24 hours from the time of the occurrence, accident or injury, (or the following work day).

All reports concerning students will be kept by the Program Chair, and Environmental Health and Safety Office,

as required by state law.

GENERAL INFORMATION

The following information should be supplied by the student who has been involved in a non-exposure

accident/injury:

NAME: ________

HOME ADDRESS: ______

______

HOME PHONE: ______WORK PHONE: ______

STUDENT #:______BIRTH DATE: ______

PROGRAM: ______

DIVISION: ______

DATE OF OCCURRENCE: ______TIME: ______am. / pm.

LOCATION OF OCCURRENCE: ______ (building, room #, name of facility, etc.)

NAME OF ANY WITNESS WHO OBSERVED THE OCCURRENCE:

NAME: ______PHONE NO.:______

NAME OF CLINICAL FACILITY PRECEPTOR AND CPCC CLINICAL COORDINATOR OCCURRENCE WAS REPORTED TO: ______

DATE REPORTED: ______

NAME OF INDIVIDUAL'S PHYSICIAN: ______

PHYSICIAN'S PHONE NUMBER: ______

PHYSICIAN'S ADDRESS: ______

NON-EXPOSURE ACCIDENT/ INJURY DESCRIPTION

Describe occurrence in factual detail. Describe how it occurred; what type of accident/injury it was (ex. swallowing crown, materials, etc., cut or puncture without exposure, instrument dropped on person, debris in eyes, allergic reaction to materials used, fall, etc.); job duties at the time of the occurrence; personal protective equipment being used, whether or not barriers were being used at the time (ex. rubber dam), whether or not standard operating procedures were being used at the time of the incident, etc.; and the area(s) involved (ex. left index finger, right palm of hand, eyes, face, throat, etc.)

Please Check All Of The Following That Apply:

YES

NO

COMMENTS

Please list all first aid measures taken at the time of the occurrence:

NON-EXPOSURE ACCIDENT/ INJURY REPORT REVIEW/FOLLOW-UP:

This occurrence report should be reviewed and signed by the following:

·  Student who experienced the occurrence

·  Program Chair

·  Division Director

·  Executive Director, Environmental Health and Safety Office

REVIEWED BY INDIVIDUAL INVOLVED: ______

(signature)

DATE: ______PRINT NAME: ______

REVIEWED BY PROGRAM CHAIR: ______

(signature)

DATE: ______PRINT NAME: ______

REVIEWED BY DIVISION DIRECTOR: ______

(signature)

DATE: ______PRINT NAME: ______

REVIEWED BY EXECUTIVE DIRECTOR, ENVIRONMENTAL HEALTH AND SAFETY OFFICE:

______

(signature)

DATE:______

SUMMARY OF ACTION TO BE TAKEN

(to be completed by affected individual)

After reviewing the occurrence/accident/injury, a full summary should be completed indicating the findings and what, if any, actions/corrections are necessary in order to avoid such occurrences from happening again in the future.

Date: ______

Doctor: ______

The following individual: ______a student

at Central Piedmont Community College was involved in a non-exposure occurrence/accident while on the

College Campus or off campus clinical affiliate. The occurrence happened on ______.

(date)

The above named individual is being referred to you for medical consultation, evaluation, testing, follow-

up as the result of this occurrence.

A copy of the non-exposure occurrence/accident/ injury report is being provided for your review and records.

Enclosed is a signed consent by ______giving you permission (individual’s name)

to release to Central Piedmont Community College a written report containing your findings,

recommendations, testing, treatment, and current condition/ status as the result of this occurrence. Should you

require further information concerning this occurrence please contact ______

(Program Chair’s name)

at: ______.

(phone number)

Your assistance is greatly appreciated.

AUTHORIZATION FOR DISCLOSURE

I, ______authorize

(individual involved)

Dr. ______to disclose

complete information to Central Piedmont Community College concerning my medical findings

and treatment as the result of the accident/injury I sustained at Central Piedmont Community College

or at an off-campus clinical affiliate on ______.

(date)

______

Signature Date

______

Signature Of Legal Guardian (If Applicable) Date

STUDENT AGREEMENT TO SEEK MEDICAL CONSULTATION

I, ______was advised by Central

Piedmont Community College to seek medical consultation, evaluation, testing, and/or treatment as the

result of the accident and/or injury I sustained while I was at Central Piedmont Community College or off

campus clinical affiliate.

I understand that Central Piedmont Community College will not cover the cost of the medical

consultation that has been advised and I will be responsible for all costs related to the accident and/or
injury.

I understand that I must carry medical, accident, and liability insurance and am responsible for

submitting all claims to my insurance carrier.

I ______do give my consent to undergo medical consultation,
evaluation, testing, and/or treatment as advised by Central Piedmont Community College.

STUDENT DECLINATION

I ______hereby do decline

Central Piedmont Community College's advice to obtain medical consultation, evaluation, testing, and/or
treatment following the occurrence/accident/injury I sustained while at Central Piedmont Community College

or off-campus clinical affiliate.

I understand that by declining to obtain medical follow-up as advised, I release Central Piedmont

Community College from any further liability and I waive on my behalf all provisions of law relating to this

occurrence/accident/injury.

______

Signature Date

______

Signature Of Legal Guardian (If Applicable) Date

8

Reviewed 2016-2017

Non-Exposure Occurrence Report