Campus Incident/Accident Report Form

Name

First Last

Status

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sex

Male
Female

Age

Place of Accident:*

Building Name*

Grounds Location*

Specify Other Location*

Responsible Person/Next of Kin:

Name

First Last

Phone

Relationship

Was responsible person notified?

Yes
No

By Whom Notified:

Date and Time of Notification

Area of Injury:

Select All that Apply*

Other Specify:

Exposure*

Were you exposed to any bodily fluids or chemicals?

Yes
No

If yes, please explain:

Emergency Care Rendered:

Was emergency care rendered?*

Yes
No

What emergency care was provided? (Select All that Apply):*

Other Specify:*

Why was emergency care not rendered?*

Refused Treatment
Other

Action Taken on Accident:

Select All that Apply

EMS Phoned: By Whom?

First-Aid Provided: By Whom?

Sent Home: By Whom?

Sent to Physician: By Whom?

Sent to Hospital: By Whom?

Name of Hospital

School Information

Reported by:*

Department

Witness:

Date

Time

:

Comments

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