Incident Report Form
(For reporting to the University Safety Office)
Incident Report Reporting Person: Telephone: Department Name: Reporting Person's Campus Address: Type of Incident:: Date of Incident: Time of Incident: Location: Room Number: Building Name: Location/area outside of a building: Responsible Party and Phone Number: Describe what happened in as much detail as possible: Describe any first aid treatment provided, in detail: List Full names and phone numbers of individuals who witnessed the incident: What corrective actions are being taken to prevent it from happening again, if any: Additional Information, if any: (Print a copy for your records)
Incident Report
Reporting Person: Telephone:
Department Name:
Reporting Person's Campus Address:
Type of Incident::
Date of Incident:
Time of Incident:
Location: Room Number: Building Name: Location/area outside of a building:
Responsible Party and Phone Number:
Describe what happened in as much detail as possible:
Describe any first aid treatment provided, in detail:
List Full names and phone numbers of individuals who witnessed the incident:
What corrective actions are being taken to prevent it from happening again, if any:
Additional Information, if any:
(Print a copy for your records)
