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Accident / Incident / Unsafe Condition Report

(optional PDF form - Accident/Incident/Unsafe Condition Report)

Today's Date: mm/dd/yyyy

I wish to report an: Accident Incident Unsafe Condition (choose one)


1. REPORTER INFORMATION:
Name: first middle initial last
I am a: Faculty member Staff member Student Visitor (choose one)

PERMANENT RESIDENCE INFORMATION (if applicable):
Home Address:
street city state zip
Home Phone: area code phone #
Cell Phone (if any): area code phone #
Home E-mail Address: (if any)

CAMPUS RESIDENCE/WORKPLACE INFORMATION (if applicable):
Building: Room:
Campus Phone: Campus E-mail:
2. EVENT DETAILS:
Event Date:
Time of day the event took place:

Event Location:


Event Description:

3. INJURIES (if applicable)
Injured Person No. 1
Name: Phone: area code   phone #
Did this injured person seek medical attention? Yes (if YES, go to line 3a.) No
3a. Care Provider:  
Care Provider Phone: area code   phone #

Injured Person No. 2
Name: Phone: area code   phone #
Did this injured person seek medical attention? Yes (if YES, go to line 3b.) No
3b. Care Provider:
Care Provider Phone: area code   phone #

Injured Person No. 3
Name: Phone: area code   phone #
Did this injured person seek medical attention? Yes (if YES, go to line 3c.) No
3c. Care Provider:
Care Provider Phone: area code   phone #

Injured Person No. 4
Name: Phone: area code   phone #
Did this injured person seek medical attention? Yes (if YES, go to line 3d.) No
3d. Care Provider:
Care Provider Phone: area code phone #
4. PROPERTY DAMAGE (if applicable)
Was there property damage? Yes No (if YES, describe below)
Property Damage Description:

5. WITNESSES (if applicable)
Witness No. 1
Name: Phone: area code phone #

Witness No. 2
Name: Phone: area code phone #

Witness No. 3
Name: Phone: area code phone #

Witness No. 4
Name: Phone: area code phone #
6. REPORTING (if applicable)
Did you report the event? Yes (go to line 6a.) No (go to line 6b.)
6a. Reported to:
Name: Phone: area code phone #

6b. If you did not report this event, explain why below:

NOTE: Before sending please read: Any event involving workplace injuries must be reported directly to Risk Management using the appropriate University form to be considered for workers compensation claims. This accident form is not intended to take the place of worker's compensation claim forms.