Student Injury/Incident Report Form

Do not use this form to report a work related injury or illness. 

Report all work related injuries or illnesses to the Safety Office using the Worker's Compensation Report form or by calling the Safety Office (496-2437).  

 

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

 

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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 as much detail as possible:

 

Briefly describe the injury (not the accident):

 

Describe in detail any and all First-aid provided:

 

List the full names and phone numbers of any witnesses:

 

Additional comments, or corrective actions, if any:

 

                                (Print a copy for your records)