Safety and Security

ACCIDENT / INCIDENT REPORT FORM

This form should be used to report any accident/ incident of the following, injury/illness to students or visitors, environmental accidents, issues related to academic affairs, issues related to research affairs, any unsafe conditions/ acts observed on campus, any behavior that violates what is stated in the universityâ€™s bylaws and regulations, property loss or damage, or theft.

Section 1- Required Information (Individual reporting the incident)

This form to be completed within 24 hours by the individual directly involved with the incident/injury [where possible] or alternate witness.

Full Name

Email Address

Phone Number

Date Reported

Employment Category

Section 2: Incident Information

Date of the Incident

Time of the Incident

Accident / Incident Location (Specific Room No or Location):

Type of Incident

If other, please specify:

Description of the Incident ( Injured Persons and Description of Injuries, or Property Damage/Loss, if any):

Management (If any):