YSU |

Meet Campus Partners

YSU Police

Youngstown State University places a high priority on the safety of its students and staff. To assure you of the best possible protection, the University employs a highly trained campus police force supported by the latest in crime-prevention education and technology. Whether you are on the YSU campus as a student, a visitor, an employee or faculty member, you can be confident that our police department is working to keep you safe.

Vehicle Accident Report

What to do in case of an accident?

STOP

Turn off the ignition

Protect

Guard the scene from further damage

Assist

Render only what first aid you are qualified to give. Don't move injured unless absolutely necessary. For serious injury, call an ambulance

Call

Notify local police department. In many states it is unlawful to leave the accident without permission. Cooperate with the authorities. If the police do not arrive at the scene proceed to the local police department and file a desk report.

Name of Person Completing this Report *

First Name

Last Name

Email of Person Completing this Report *

Is Vehicle Drivable? *

YES

NO

Additional Information

Indicate location of all traffic signals, stop signs, speed limit signs, etc. Indicate location of all vehicles/pedestrians and witnesses.

Date of Accident *

Year

Month

Day

Time of Accident *

Hour

:

Minute

am

pm

Location of Accident

Street *

Street

City *

State *

Zip Code *

Description of Accident *

Weather Conditions *

Weather Conditions Other...

Speed Limit *

Authority Contacted

Name of Authority *

Badge Number *

Report Number *

Citation Issued? *

YES

NO

If so, against whom:

University Vehicle

VIN *

Year *

Year

Month

Day

Make *

Model *

Plate Number *

State *

Driver's Name *

First Name

Last Name

Driver's Address *

Driver's City *

Driver's State *

Driver's Zip Code *

Driver's License Number *

Phone Number *

Description of Damage *

Description of Injuries *

Other Vehicle Information

Description of Property *

If Auto - Year, Make, Model, Plate #

Driver's Name *

First Name

Last Name

Driver's License Number *

Address *

Phone Number *

Owner's Name and Address if Different than Driver

Description of Damage *

Description of Injuries *

Injured Person A

Name

First Name

Last Name

Address

Phone Number

Was this person a Pedestrian?

YES

NO

Insured Vehicle

Other Vehicle

Extent of Injuries

Injured Person B

Name

First Name

Last Name

Address

Phone Number

Was this person a Pedestrian?

YES

NO

Insured Vehicle

Other Vehicle

Extent of Injuries

Injured Person C

Name

First Name

Last Name

Address

Phone Number

Was this person a Pedestrian?

YES

NO

Insured Vehicle

Other Vehicle

Extent of Injuries

Injured Person D

Name

First Name

Last Name

Address

Phone Number

Was this person a Pedestrian?

YES

NO

Insured Vehicle

Other Vehicle

Extent of Injuries

Was anyone taken from the scene by ambulance? *

YES

NO

Witnesses, Including Passengers A

Name

First Name

Last Name

Address

Phone Number

Insured Vehicle

Other Vehicle

Other (Specify)

Witnesses, Including Passengers B

Name

First Name

Last Name

Address

Phone Number

Insured Vehicle

Other Vehicle

Other (Specify)

Witnesses, Including Passengers C

Name

First Name

Last Name

Address

Phone Number

Insured Vehicle

Other Vehicle

Other (Specify)

Witnesses, Including Passengers D

Name

First Name

Last Name

Address

Phone Number

Insured Vehicle

Other Vehicle

Other (Specify)

Leave this field blank

General Insurance Certificates

Third Parties who contract with YSU may access the following Certificates of Insurance listed below. A third party is considered an Additional Insured on the General Liability and Property policies when such an obligation exists in a written contract, per blanket endorsement in our policies.

General Liability/ Auto Liability/ Student Internship & Practicum

Insurance Coverage

The following is a summary of the IUC-IC coverage. The summary is not intended to provide limits, deductibles to premium information.

Automobile Physical Damage

Provides damage protection for university owned, leased, loaned, or rented vehicles.

Ultra Ambassadors

Faculty who are experienced with teaching in Ultra can apply to become Ultra Ambassadors. Ambassadors will play a crucial and influential role within their departments by communicating information to and assisting their peers.

OBLIGATION

Attend an Ultra Ambassador training program (TBD time, length).
Function as peer support for your respective department/college.
Serve as an ambassador during your department/college’s training semester and one semester following.

Incident and Injury Reporting Form

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

Are you completing this form on behalf of someone else (the affected individual)? *

YES

NO

Reporting Individual Information

Your Name *

Your Email Address *

Your Phone Number *

Personal Information

Name of Person Involved in the Incident *

Gender

MALE

FEMALE

Date of Birth *

Year

Month

Day

Street Address *

City *

State *

Zip Code *

Email Address *

Home/Mobile Phone Number *

Employee / Non-Employee *

Employee

Non-Employee

Employee Information

Department *

Job Title *

Date of Hire *

Supervisor Name *

Supervisor phone/email *

Your e-Signature *

Current Date *

Year

Month

Day

Leave this field blank

Claims Reporting

YSU requires timely and proper reporting of incidents and accidents that could become insurance claims so that insurance coverage is not jeopardized in addition to claims being resolved and paid timely (if coverage applies). All incidents and accidents can be reported to EHS by completing the online form below. Depending on the situation, additional information may be needed to determine if a claim must be submitted to our brokers. Questions about this process can be directed to Julie Gentile, Director of EHS.

Search

Meet Campus Partners

YSU Police

Vehicle Accident Report

What to do in case of an accident?

STOP

Protect

Assist

Call

General Insurance Certificates

Insurance Coverage

Ultra Ambassadors

OBLIGATION

Incident and Injury Reporting Form

Claims Reporting

Care Team

Care Team

Care Team

Pages