Accident/Incident/Unsafe Condition Report - Digital

Accident/Incident/Unsafe Condition Report - .PDF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FM Logo
Report of Accidents/Incidents/Unsafe Conditions
 

Today's Date: mm/dd/yyyy

This event was/is a: 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 no:    
Cell Phone (if any): area code:phone no:   
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 no: 
Did this injured person  seek medical attention?  Yes (if  YES, go to line 3a.) No 
3a. Care Provider Name:   Care Provider Phone: area code phone no: 
----------------------------------------------------------------------------------------------------------------------------------------------------
Injured Person No. 2  Name:    Phone:  area code: phone no: 
Did this injured person  seek medical attention?  Yes (if  YES, go to line 3b.) No  
3b. Care Provider Name:   Care Provider Phone: area code phone no: 
-------------------------------------------------------------------------------------------------------------------------------------------------------
Injured Person No. 3   Name:    Phone:  area code: phone no: 
Did this injured person  seek medical attention?  Yes (if  YES, go to line 3c.) No  
3c. Care Provider Name:   Care Provider Phone: area code phone no: 
-------------------------------------------------------------------------------------------------------------------------------------------------------
Injured Person No. 4  Name:    Phone:  area code: phone no: 
Did this injured person  seek medical attention?  Yes (if  YES, go to line 3d.) No 
3d. Care Provider Name:   Care Provider Phone: area code phone no: 

======================================================================================
4. PROPERTY DAMAGE (if applicable)
Was there property damage? YesNo (if YES, describe below)

 Property Damage Description:

=======================================================================================
5.  WITNESSES (if applicable)
Witness No. 1  Name:    Phone:  area code: phone no: 
Witness No. 2  Name:   Phone:  area code: phone no: 
Witness No. 3  Name:   Phone:  area code: phone no: 
Witness No. 4  Name:   Phone: area code: phone no: 

=======================================================================================
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 no: 


 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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Your report has been sent!
Thanks!

Return to Top of form

Return to FM Home Page