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PEAR Accident Report Form

This form is meant to be filled out after the incident occurred for informational purposes only. In the event of an emergency, or if you need immediate help, please call 911 or contact Campus Security at (507)222-4444.

PEAR Accident Report Form

This form is meant to be filled out after the incident occurred for informational purposes only. In the event of an emergency or if you need immediate help, please call 911 or contact campus security x4444.

Name of Reporter(Required)

Email(Required)

Student

Faculty/Staff

Other

Work Title

Information About Injured Party

Name(Required)

First Last

Is the Injured Person a:(Required)

Carleton Student

Carleton Faculty/Staff

Guest of the College

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Cell Phone

Department or Office

Is the injured person a minor?

Yes

No

Responsible Party

Please provide name and contact information for the minor's parent or guardian

Information About The Incident

Date of the Incident(Required)

MM slash DD slash YYYY

Time of Incident(Required)

Hours

:

Minutes

AM/PM

Which facility did the incident occur?

Cowling

Cowling Pool

Laird Stadium

Rec Center

Athletic/Rec Center Fields

West Gym

West Gym Thorpe Pool

Other

Activity Description

General Rec Center Use

Rec Center Program/Class

Intramurals

PE Class

Sport Clubs

Open Swim

Varsity Sport

Other

Name of Club, Sport or Class

Description of Incident(Required)

Please describe the incident in as much detail as possible, including what happened, how it happened and factors leading up to the incident

Describe the Injury(Required)

Please describe the injury in as much detail as possible, including type of injury (laceration, sprain, etc.) and part of the body.

Care Provided

Was care provided?

Yes

No

Care Refused by injured individual

Name and work title of care provider if different from person filling out this form

Care provided

Please describe in as much detail as possible the care provided

Was Security called?

Yes

No

If no, why?

Did the individual refuse or was the injury or incident not severe enough?

Was EMS called?

Yes

No

If yes, by whom?

Was individual transported to an emergency facility?

Yes

No

Did the injured individual return to activity?

Yes

No

Was student referred to go to SHAC for follow up?

Yes

No

Additional Information

Please only answer the questions that apply to this incident

WITNESSES

Provide names and contact information (phone and/or email) of any witnesses

Provide names of lifeguards/monitors/supervisors on staff at time of incident

Water condition/clarity at time of incident

Pool deck condition at time of incident

Field condition at time of incident

Any other information you think we should know?

You can upload any supporting documents or photos here

Max. file size: 100 MB.

Phone

This field is for validation purposes and should be left unchanged.

Δ

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Physical Education, Athletics, and Recreation

Chair: Gerald Young

Administrative Assistant: Annie Larson

Physical Education, Athletics, and Recreation pages maintained by Annie Larson

This page was last updated on 4 August 2022

One North College StNorthfield, MN 55057USA

507-222-4000

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