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Accident Report Form

Accident Report Form

Accident Report Form

This form should be utilized to report accidents that occur on 乱伦视频's campus or involve university employees, students and guests. Reports should be submitted within 24 hours of the accident.

Information about Injured Person
Legal Name*
First Last
Mobile Phone*
University Affiliation*
- Student
- Employee
- Visitor/Guest
- Vendor/Contractor
Provide name of supervising company and project worked while injured.
Supervisor's Name*
First Last
Shift Worked*
Local Address*
Street Address Address Line 2 City State ZIP Code
Home Address (if different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Information about the Incident
Date*
MM slash DD slash YYYY
Time*

: Hours

Minutes

AM/PM
Location of Accident*
Please provide street address or closest landmark, when possible.
Accident Description*
Describe what happened, how it happened, factors leading to the event, etc. Be as specific as possible. If a University vehicle was involved, please include the license plate number.
Photo Upload
Drop files here or

Max. file size: 49 MB.
Please attach photos of vehicle or property damage, if pertinent.
Description of Injury*
Please describe the injury (laceration, sprain, etc.), the part of body injured, and any other information known about the resulting injury(ies).
Witness Information
Provide names, phone numbers and email addresses of witnesses, if present.
Police report number
Complete only if police were notified (Campus Safety & Police, 乱伦视频 Town Police, Burlington Police, etc.)
Did you seek medical treatment?*
- Yes
- No
- Refused
What treatment facility did you use?*
Did you return to work after receiving medical treatment?
- Yes
- Yes, with restrictions
- No
Describe restrictions
Employees must provide return to work restrictions to supervisor and Risk Management and Insurance. Employees must be approved to return before resuming job duties.
Reporter Information
Individual Submitting Report*
First Last
Signature*
Date Report Completed*
MM slash DD slash YYYY
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

Risk Management and Insurance
Risk Management
- Health, Safety, and Environmental Management
- Workstation Evaluation Request
University Insurance

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336.278.2000

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