Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Name* Required

Additional Location Details

Exact Location

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Claim or Report:* Required

Sex:

Employment Status:* Required

Faculty

Staff

Student Worker

Student

Does this person speak English:

Name of Reporting Department:

Date and Time of Injury/Incident Occurred:

This is the time of occurrence, not reported.

* Required

Date injury or Incident Reported:

Time Injury or Incident Reported:

Severity of Injury:

Describe how the injury or incident occurred:* Required

Was this person performing his/her regular duties?

Was the injured person wearing personal protective equipment (PPE)?

Was training provided to this person to perform this task or operate this equipment?

Yes

No

Not Applicable

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