Attachment 14 FLETC Form 066-01-20.pdf

DEPARTMENT OF HOMELAND SECURITY

FEDERAL LAW ENFORCEMENT TRAINING CENTERS

INJURY INFORMATION

The purpose of this form is to identify student injuries while training at the Federal Law Enforcement Training Center and for internal tracking of student injuries in order to provide a safe training environment.

Print Clearly

Staff Name:

Agency: Division:

Print Clearly

Student Name:

Class Name/ #: Agency:

INJURY INFO:

Date of injury: Time of injury:

Injured body part(s): Upper Back Chest Finger Foot (Specify left/right) Mid Back Shoulder Abdomen Toe

Lower Back Upper Arm Hip Head Elbow Thigh Neck Forearm Knee Face Wrist Lower Leg Eye Hand kl An e Other/explain:

Injury occurred during:

Firearms Training Other/Define:

Pyrotechniques Training

Physical Techniques Training

Marine Training

Driver Training

Explain how injury occurred/Give details:

Privacy Act Statement The following information is provided in accordance with the Privacy Act of 1974 5 U.S.C. 552a(e)(3): Authority for the collection of this information is 5 U.S.C.

4101 at seq., Executive Order No. 11348 and the DHS Delegation Number 7950. The primary use of this information is to evaluate fitness to participate in training activities conducted at the FLETC and for internal tracking of student injuries to provide a safe training environment while on FLETC. Routine uses of this information as established and published in accordance with 5 U.S.C. a(3)(4)(D), include transfer of this information to officials of the FLETC and your agency.

Disclosure of this information is, voluntary. However, it may not be possible for you to receive training at the FLETC if the information is not provided.

Injurer's Signature:

FLETC Form 066-01-20(7/2023) Page 1 of 1

Health Services Contract Part 9. Attachment 14