NOTE:  FAILURE TO COMPLETE ALL SECTIONS OF THIS FORM MAY DELAY CLAIM AND/OR PAYMENT OF BENEFITS.

Incident Date  

Full Name of Injured Individual  

Email Address of Injured:  

Local Address      
                              Street & Number                         City / State                    Zip Code

Telephone     Date of Birth   
                            Home                      Work

Age  Sex         BYU-I #  

Marital Status    (Single, Married, Divorced, Widowed)  

Staff      Administrative      Faculty       Student  

 Department   Position Title    

 Is this a work related incident?     Yes      No 

 Is the victim current on vaccinations?     Yes      No 

Time of Incident  AM      PM 

Date supervisor notified   Time supervisor is notified

Name of Supervisor/Instructor 

Location of Accident or Exposure 
                                                         (Building, room, off-campus address, etc.)

How did the Incident Occur?  

  (Give as much detail as possible. Name tool, object, behavior, etc. that caused injury)                      
 

 Did Individual Receive Medical Care?   Yes       No       First Aid Only

Where was medical treatment received?  None    Health Center    Hospital    Physician 

Attending Physician or Hospital   

Describe any treatment given: 

Name of Witness  Contact Person 

Date submitted report  Contact Phone #

Corrective Actions (to be filled out by the supervisor):

Responsible Party  Target Date 

NOTICE:    IMMEDIATELY REPORT ALL NEEDLE STICKS TO UNIVERSITY SAFETY OFFICE.  

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