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 Address* 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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Injured Person's Information

Injured Person's Name

Injured Person's W#

Injured Person's Status

Injured Person's Supervisor

Injured Person's Job Position/Title

Incident Information

Date of Incident

Time of Incident

Task being performed when incident occurred

Incident Results

Injury

Fatality

Property Damage

Near-Miss

Number of Workdays Lost

Witness' Name(s)

Describe how the incident occurred

What contributed to this incident?

Was safety equipment provided?

Was safety equipment used?

What safety equipment was provided/used?

How to prevent this type of future incidents?

Injury Information

Medical Treatment

First aid administered at workplace

Medical Treatment Required

Doubts that this injury is not work-related?

Signature Section

Signature of Supervisor

Add Supporting Documents

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