Incident 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: For "Location" below, type a name or address to search buildings and outdoor areas on campus. If off campus, select "Off Campus" for "Campus, Building, or Outdoor Area."

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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Employee Information

Home Address* Required

W#* Required

City, State, Zip Code* Required

Date of Birth* Required

Gender* Required

Phone* Required

Employment Type* Required

Employment Status* Required

Job Title* Required

Date Hired* Required

Wage Rate* Required

Hours per Week* Required

Department* Required

Supervisor* Required

Supervisor's Phone* Required

Incident and Injury Information

Date and Time of Incident* Required

Time Shift Began* Required

How Did the Incident Occur?* Required

Parts of Body Injured and Type of Injury* Required

Previous injury?* Required

Date of Previous Injury

Describe previous injury

Was safety equipment provided?* Required

Was safety equipment used?* Required

What safety equipment was provided/used?* Required

Witnesses: Names & Phone Numbers* Required

Medical Treatment Received?* Required

Date treatment received

Type of treatment received* Required

None
On-site treatment
Emergency Room
IHC WorkMed
Hospitalization
Other

Physician Name

Physician Telephone* Required

Clinic/Hospital Name

Clinic/Hospital Address

How to prevent future incidents of this type?* Required

Employee Signature* Required

Add Supporting Documents

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

Reporter Info

Location

Employee Information More information

Incident and Injury Information More information

Add Supporting Documents

Employee Information

Incident and Injury Information