Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

Loading…

Claim or Report:* Required

Sex:* Required

Employment Status:* Required

Faculty

Staff

Student Worker

Student

Does this person speak English:* Required

Name of Reporting Department:* Required

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?* Required

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

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

Yes

No

Not Applicable

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