Incident and Injury Reporting Form

Use this form to report workplace incidents & accidents, such as injuries, property damage or near-miss (close calls).

Are you completing this form on behalf of someone else (the affected individual)?
Reporting Individual Information
Personal Information
Gender
Employee / Non-Employee
Employee Information
Incident Information

For non-employee students, the supervisor may be the Faculty advisor/coordinator, instructor or Department Chair.
Specific location or area where the incident occurred, such as building and room number.
Describe what happened, including the activity that was being performed just before the incident occurred.
Injuries/Illness?
Medical Treatment
Hospitalized Overnight as an In-Patient
Witness?