ACCIDENT REPORT

Date of accident: November 16, 2016_ Time: 11:00 PM

Name of injured person: Syra Jeane R. Cos

Address: Nasipit, Talamban, Cebu City
Phone Number(s):09068151950
Date of birth: October 10, 1996________ Gender: Female____

Type of injury: Cat Bite

Details of accident:
The cat roam around our hallway in the 4 th floor of the Building 2 of the Girls Dormitory
inside the campus. I went outside our room to go to the toilet. After going to the toilet, the cat
went near me asking for food. While the cat was very near to me, I accidentally stepped on its tail
without me noticing that it was its tail that I stepped on. The cat bit me twice on my right leg.
Then, I right away cleaned the wounds. The next day, it seemed okay. On Friday, November 18,
2016, my roommate told me that we should go to the nearby hospital.

Signature of injured party: ___________________________ _________________________

Date

08/31/17 364623871.doc 1/1