Incident Report • CampusOptics

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

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Injured Party Information

Status

A-State ID

Full Name

Home Address

Phone Number

Date of Birth

Date of Hire

Description of the Incident

Date of Injury

Time of Incident

Location of Incident

What was the employee doing just before the incident occured?

What happened?

What was the illness or injury?

What object or substance directly harmed the employee?

If the employee died, when did the death occur?

Immediate Action Taken

If this is an employee, have you contacted the nurse hotline?

Did the injured part receive treatment?

Yes
No treatment necessary
No treatment was refused
No injured part refused to provide personal information

Name of health care facility or physician

Address of healthcare facility or physician.

Was the employee treated in an emergency roon?

Was the employee hospitalized overnight?

Witnesses

Name and contact number for witnesses

Additional Information

Additional Comments

Add Supporting Documents

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

Reporter Info

Location

Injured Party Information More information

Description of the Incident More information

Immediate Action Taken More information