Incident Report Form – Risk, Safety, & Resilience

Section 1: Required Information
(Individual reporting the incident)
Name*
First Last
Email*
Address (Home or Work)*
Street Address Address Line 2 City State ZIP Code
Phone*
Date Reported*
MM slash DD slash YYYY
Status*
- Student
- Faculty
- Staff
- Visitor
- Contractor
Visitors: Please describe your purpose for being on campus.
Example: Campus tour

Section 2: Incident Information
Date of the Incident*
Month
Day
Year
Time*

: Hours

Minutes

AM/PM
Campus Location*
Building (if applicable)
Room (if applicable)
Type*
- Injury/Illness
- Unsafe Condition
- Environmental Spill
- Fire
- Laboratory Spill/Incident
- Non-Vehicular Accident
- Prohibited Discharge to Storm Sewer
- Other
You selected "other," please describe below:
Description and cause of the incident*
Indicate conditions such as weather, construction, cleaning, etc. with your explanation. Visitors should include their purpose for being on campus.
Name of Parties Involved or Witnesses
Continue to add as many individuals as needed by clicking the (+) sign to the right of each row.
First Name Last Name

First Name	Last Name

First Name	Last Name	Description of Injuries

Item	Description	Approximate Value