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 Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

Loading…

Victim Information

Date and Time of Accident

Victim Information: Name

Age

Gender

Phone

Address

City

State

Zip

Victim is

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)

Description of the Accident/Incident

If physical injury occurred, describe the body parts affected

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

Position

Signature

Date

Add Supporting Documents

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