Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Name* Required

Additional Location Details

Exact Location

Loading…

Status

A-State ID

Full Name

Home Address

Phone Number

Date of Birth

Date of Hire

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?

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?

Name and contact number for witnesses

Additional Comments

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