Incident and Injury Reporting Form

Use this form to report workplace incidents & accidents, such as injuries, property damage or near-miss (close calls).

Reporting Individual Information
Personal Information
Employee Information
Incident Information
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Specific location or area where the incident occurred, such as building and room number.
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For non-employee students, the supervisor may be the Faculty advisor/coordinator, instructor or Department Chair.
Describe what happened, including the activity that was being performed just before the incident occurred.