Reporting a Campus Injury

As an instructor or dean, if you are notified that a student (who is not an employee) was injured, you should:

• Download the Non-Employee Injury Incident Report.
• Complete the form as soon as possible.
• Email the completed report to risk@fhda.edu within 24 hours of the incident.

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 Foothill-De Anza district's Workers Comp webpage 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 page 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.

Students who are injured on campus may file an insurance claim under the Foothill-De Anza district's student accident policy. The district's insurance is secondary to your primary insurance.

You can download the Student Accident Insurance Claim form 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.

The Foothill-De Anza Community College District is following the County of Santa Clara guidelines for preventing spread of respiratory viruses, including COVID-19. Learn more about how the District is handling ongoing updates.