Student/Visitor Incident Report

For non-work related injuries/illnesses

Time of Injury/Illness Time of Injury/Illness : HH MM AM/PM
Time Time : HH MM AM/PM
Name Name First Last
Status:
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Telephone Number Telephone Number - ### - ### ####
Did it occur on campus?

Did it occur on campus? Yes No
If yes, campus location (e.g., building, parking lot):
If no, address of location: If no, address of location:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Specific location where injury or exposure occurred (e.g., stairs, docks, sidewalk, lab):
Nature of injury/illness(e.g, cut, sprain, illness):
Body part involved (e.g., left arm, right eye):
Cause of injury/illness (e.g., slip or fall, chemical):
How and why did this injury/illness occur?
Will medical attention be required for this injury/illness?

Will medical attention be required for this injury/illness? Yes No
List of Witnesses and statements
Reporting Person's Contact Information (if filled out by other than the injured party): Reporting Person's Contact Information (if filled out by other than the injured party): First Last
Email
Telephone Number: Telephone Number: - ### - ### ####