Incident Report • CampusOptics

Please complete the following questions with as much detail as possible. If the incident happened in a parking lot on campus, please associate the location details with the building closest to where the incident took place. If it occurred off campus, please associate your location to the building of the department of which you are associated.

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

Loading…

Please complete the following.

Name and Title of Individual Injured if applicable* Required

Address and Phone number of Individual Injured if applicable* Required

Description of Incident* Required

Date and Time Incident Occurred* Required

Did the incident occur on or off campus?* Required

Circumstances Leading to Incident* Required

Did the incident result in injury to anyone involved?* Required

Details of Personal Injury* Required

Did the individual seek medical attention?* Required

If yes, list name and location of medical facility where medical attention was received.

Were there any witnesses?* Required

If yes, list witnesses name, address, and phone number

Witness account of incident

If applicable, was PPE worn at time of incident?* Required

If yes, list PPE worn by all individuals

Was there damage to property?* Required

List property damaged

Were emergency services contacted?* Required

Was the incident reported immediately?* Required

Date and time incident was reported

Was the incident a breach of safety protocol?* Required

Was the incident a result of mechanical failure?* Required

Describe the mechanical failure

Did the incident involve a third party, vendor or contractor?* Required

List third party involved

Add Supporting Documents

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