17³Ô¹Ï

Reporting a Campus Injury

Here's what to do if you're a student or employee who is injured on campus.

If you are an employee, including a student employee, SKIP to Employee Injuries instructions below.

Student Injuries

If you are a student who is injured on campus, you should notify an instructor or dean of the division where the incident occurred â€” as soon as possible.

NOTE: If you are injured while working as student employee, please follow the  listed below for employees.

For instructors or deans who are notified of an injury involving a student who is not an employee should

• Download the  and fill it out
• Email the completed report to risk@fhda.edu within 24 hours of the incident.

Insurance Claims

Students who are injured on campus may file an insurance claim under the 17³Ô¹Ï-De Anza district's student accident policy. 

• The district's insurance is secondary to your primary insurance.
• You can download the  and fill in the required information.
• Bring the form to a division dean to complete the top section.
• After the form is completed, follow the instructions at the top of the form to submit your claim by mail or email. 

Employee Injuries – Including Student Employees

If you are injured on campus while working as an employee or student employee, you must notify your supervisor immediately. You may also be required to complete certain forms.

• Visit the 17³Ô¹Ï-De Anza district's and download the document called Employee/Student Employee Injury Claim Process, which explains the required procedure for notification and reporting.
• Next, scroll down on the to locate and download these three forms:
  • • State of California Employer's Report Form (Form 5020)
    • Workers' Comp Report of Injury Form
    • DWC-1 Form
• After you download the forms, fill them out and send the completed forms via email to MyBenefits@fhda.edu or fax them to 650.949.6299.