Report • CampusOptics

Reports should be turned in within 24 hours of the incident. Please include your home or cell phone number in the "Phone Number" field seen below in the "Reporter Info" section.

PLEASE NOTE: Type/select "OFF CAMPUS" in the Name line under Location (for clinicals, off-campus workers). Type the address of injury in the Additional Location Details line if the injury occurred off-campus.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

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Employee/Employment Information

Employee Phone* Required

Home Address* Required

W#* Required

City, State* Required

Zip Code* Required

Date of Birth* Required

Department/Program* Required

Work phone number

Occupation/Job Title

Date Hired (if applicable)

Employment Status

Wage Range

Number of days worked per week

Supervisor Name

Injury/Illness/Exposure Incident Information

Date employer/supervisor was notified

Time Shift Began

Time of Injury (if known)

Accident Premises

Part(s) of Body

Type of Injury/Illness/Exposure

Side of Body

Cause of Injury/Illness/Exposure* Required

Was safety equipment provided?

List all safety equipment provided.* Required

Describe the injury/illness/exposure and how it occurred.* Required

Specific activity/work process employee was engaged in when the injury/illness/exposure occurred.

Equipment, materials, chemicals employee was using when accident occured.

Initial Treatment

Date treatment was received (if treatment was received)

Physician Information

Care facility where you were treated.

Witnesses: Names & Phone Numbers

What could be done to prevent the injury/illness/exposure from happening in the future?

Employee Signature* Required

Bloodborne Pathogens Exposure Section

Device involved when exposure occurred.* Required

Route of exposure.* Required

What substances were involved?* Required

Was the source individual identified?* Required

Has testing been initiated for the source individual?* Required

Add Supporting Documents

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