Report • CampusOptics

Complete for any injury or illness that is experienced during a laboratory or class. This form should be used for students, staff, and faculty.

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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Individual Involved in Accident

Name of injured person or 900#

Date Occurred

Job Title

Department

Home Phone Number

Cell Phone Number

Where did the accident occur?

Describe injured person’s activities just prior to the accident and explain how the accident happened:

Describe person’s injuries and list affected body parts:

What type of first aid care provided?:

Was medical treatment required?

If yes, who provided treatment:

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