Campus Accidental Injury Report

For reporting non-employee incidents only


Name, (Last, First, Initial) __________________________________________ Birth Date:____________________________	Address (include phone number) ______________________________________ Telephone #: _____________________________

Date of Accident: (date & time)

Date _______________________

Time _______________________

Location of Accident _____________________

Building ____________________ Room_____

Were you an employee at the time of accident?

Yes_____ No ____

If so, who was your supervisor? ________________________________

____

Witnesses: (Names, address, & phone)

________________________________________________

________________________________________________
________________________________________________

Describe Injury in Detail:: (use back of this page if needed)

___________________________________________________________________________

Severity: ( ) Non-disabling ( ) Disabling ( ) Fatal

EMERGENCY CARE & PATIENT STATUS:

( ) First Aid only ( ) Treatment at University Health Center

( ) Treatment at Local Hospital ( ) Confinement at Hospital ( ) Other

DETAILS OF ACCIDENT: (Describe event, conditions including environmental, physical and emotional/personal factors, which contributed to the injury. Use reverse side if necessary.) Be very Specific:

____________________________________________________________________________

___________________________________________________________________________

_______________________________________________________________________

REPORT PREPARED BY

SIGNATURE____________________________________________

ADDRESS __________________________

Please complete this report in full. Return to Safety & Risk Management Department, University Services Building, Room 130 as soon as possible. Any questions, please call X1793.