Injury Report

Information About the Person Submitting This Report
Name: * First Last
Email *
Injury Information
Names of people injured:
Who witnessed the injury?
The injured people were (check all that apply): *
Student(s) Visitor(s) Student worker(s) that were working at the time of the injury Employee(s) that were working at the time of the injury
If those injured were student workers or employees working at the time of injury, did they initiate workers’ compensation paperwork with the human resources office?
What was the nature of the injury? *
Date injury occurred: * MM/ DD/ YYYY
Time injury occurred: HH : MM : SS AM/PM
Where did the injury occur? *
Briefly describe the nature of the injury. *
Referral Information
Was the person referred off campus? *
What kind of follow-up has been provided, if any?
Did the person accept the referral? *
Where were they referred? *
How were they transported? *
Was a taxi voucher given to the student? *
Was an ambulance or rescue squad called? *
Do Not Fill This Out