Student Accident Reporting Form -

The College’s Safety Committee asks all students who are injured on campus or during College-related activities to complete this questionnaire. Part-time students, students in summer or special programs, graduate students and students from other colleges who are taking courses, conducting research, or participating in a Smith College activity should also complete this form. NOTE: Students injured while working as an employee of Smith College should contact their supervisor and complete the “Report of Job-Related Accident” form.

This information will be used to assess accident prevention programs at Smith. When you have completed the upper section of the form, please give it to the health care provider or faculty member for their comments. This form should be completed within 24 hours after the accident—it is most helpful when received then-- but will be accepted after that time.
Name *
Class *
Age *
ID# *
Cell Phone *
Email Address *
Date of Injury *
Time *HHMMAM/PM
Location (Building, room number if applicable)
Who is the Laboratory or Research Faculty member supervising your work? *
What activity were you engaged in?
Describe how the accident occurred.
Nature and extent of the injury?
Where was treatment received? *
Health ServicesCooley DickinsonOther
How did you get there? *
Public SafetyWalkedOther
Do you have any suggestions to prevent similar accidents?