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      Student Injury/Incident Report Form

Do not use this form to report a work related injury or illness.  Report such injuries or illnesses to the Safety Office using the Work Related Injury/Illness Reports/Claims form or by calling the Safety Office (496-2457).  

All other accidents that occur on campus should be reported as soon as possible to the Safety Office using this Injury/Incident Report Form.   Incident reports should be filed for accidents involving students or visitors and for accidental university property damage.  (Intentional acts of violence or vandalism should be reported directly to the University Police by calling 496-3000.)

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Online Injury/Incident Report Form

Reporting Person:    Telephone: 

Department name:   

Email Address:

List full name of injured person-birth date-address-phone number:

Activity:

Type of Injury/Incident: 

Date of Incident:

Time of Incident:  

Location of Incident: 
Room:  Building Name: 

Location outside of a building:

Describe what happened in detail:

Briefly describe the injury:

Describe in detail any and all First-aid provided:

List full names and phone numbers of any witnesses:

Additional comments, or corrective actions, if any: