Incident Report • CampusOptics

Use this form for non-work related accidents or incidents. If this involves a vehicle, please use the Vehicle Accident Reporting Form

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Victim Information

Date and Time of Accident* Required

Victim Information: Name* Required

Age

Gender

Phone* Required

Address* Required

City* Required

State* Required

Zip* Required

Victim is* Required

If other above, please describe

Family/Emergency Contact (name and phone number)

If the victim is a minor, were the minor’s parents contacted (if not present)?

Program Participating in

Program Supervisor/Instructor

Accident/Incident Information

Location where the accident occurred and cause (be specific)* Required

Description of the Accident/Incident* Required

If physical injury occurred, describe the body parts affected* Required

Witnesses to Accident

Witness 1: Name

Witness 1: Phone

Witness 1: Email

Witness 2: Name

Witness 2: Phone

Witness 2: Email

If Care Provided

Name of person(s) and/or agency that provided care

Describe the care provided

Were emergency medical (EMS) personnel called?

Was the victim transported to an emergency facility?

Did person return to activity?

Were Police called and responded to the incident?

Report Prepared By

Report Prepared By: Name* Required

Position

Signature* Required

Date* Required

Add Supporting Documents

Add files to upload as supporting documentation along with your incident report.