Incident Report • CampusOptics

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Description* Required

Occurred At* Required

Date of Injury* Required

Time of Injury* Required

Was Medical Treatment Required?* Required

First aid only* Required

Time Lost From Work* Required

Last day worked * Required

Name and Address of Practitioner* Required

Witnesses* Required

Date reported to my supervisor* Required

Other body parts injured* Required

Dominant arm* Required

Previous injury?* Required

If yes to previous injury, date?* Required

Previous injury practitioner* Required

Employee Signature* Required

Cause/Occurrence* Required

OSHA Codes* Required

Incident OSHA "recordable"?* Required

Name of Authorized Representative* Required

Have you contacted SIUE Workman's Comp Claim office?* Required

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