Incident Report • CampusOptics

Reports should be turned in within 24 hours of the incident.

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

Loading…

Injured Person's Information

Injured Person's Name* Required

Injured Person's W#* Required

Injured Person's Status* Required

Injured Person's Supervisor* Required

Injured Person's Job Position/Title* Required

Incident Information

Date of Incident* Required

Time of Incident* Required

Task being performed when incident occurred* Required

Incident Results* Required

Injury
Fatality
Property Damage
Near-Miss

Number of Workdays Lost* Required

Witness' Name(s)* Required

Describe how the incident occurred* Required

What contributed to this incident?* Required

Was safety equipment provided?* Required

Was safety equipment used?* Required

What safety equipment was provided/used?* Required

How to prevent this type of future incidents?* Required

Injury Information

Medical Treatment* Required

First aid administered at workplace
Medical Treatment Required

Doubts that this injury is not work-related?* Required

Signature Section

Signature of Supervisor

Add Supporting Documents

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

Reporter Info

Location

Injured Person's Information More information

Incident Information More information

Injury Information More information

Signature Section More information

Add Supporting Documents

Injured Person's Information

Incident Information

Injury Information

Signature Section