Report • CampusOptics

Complete this form for incidents or injuries occurring on campus and during off campus functions. Provide an NA response for not applicable.

All injured employees or their supervisor must call Benefits immediately at 678-407-5489 to report injuries.

Contact EHS at 678-407-5122 with questions and concerns.

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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Reporter Contact Information, include phone, email, and campus address if applicable.

Full Name

Cell Phone

Home/Other Phone

Home Address

City

State and Zip Code

Name

Phone Number

Relationship to Injured

Address

City

State

Sponsor / Faculty Mentor's Name

Department

Phone / Campus Address

Reason for campus visit

Date Occurred

Description of How Injury/Incident Occurred:

Type of Injury and Exact Body Part(s) Affected

Witness 1 Name

Witness 1 Phone

Witness 2 Name

Witness 2 Phone

Date of Treatment

Time of Treatment

Additional Information

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