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Main Office: CA Highway 1, Bldg 2026
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- Click ‘Get Form’ to open the Student Injury/Exposure Report in the editor.
- Begin with Part 1: Instructor Statement. Fill in the STUDENT NAME, DATE & TIME OF INJURY/EXPOSURE, LOCATION OF OCCURRENCE, COURSE TITLE AND INSTRUCTOR NAME, and a DESCRIPTION OF INJURY/EXPOSURE.
- If applicable, indicate whether the student has declined medical treatment by adding instructor’s initials in the designated area.
- Complete the section for INSTRUCTOR’S RESPONSIBILITY by following the outlined steps for serious or minor injuries and ensure all necessary notifications are made.
- Proceed to Part 2: Student Statement. The student should fill in their details including STUDENT ID #, MAILING ADDRESS, PHONE NUMBERS, and repeat the injury/exposure information.
- The student must also indicate if they decline medical treatment and provide a reason if applicable before signing and dating the form.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2019 | 4.8 Satisfied (52 Votes) |
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Related links
General Information: (916) 654-2852 (707) 445-6600 district.1.pio@dot.ca.gov (510) 286-4444 (805) 549-3111 (213) 897-1200 (760) 872-0601
Highway 1 south Take Exit 406 (Lightfighter Drive, CSUMB main entrance) Highway 1 Exit at Lightfighter Drive (Exit 406) 831-582-3000