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Injury, Sudden Illness, or Accident Reporting Form


This form should be used to report all injuries, illnesses, or accidents that take place on campus. If you are reporting incidents of behavior concerns, campus safety, or suspicious activity, use the Incident Report form.

Reporting Party Information

Provide detailed information should follow up be needed.

 
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(injured person or witness)
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(numbers only, omit spaces and dashes)
Email address must be of a valid format.
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must be formatted YYYY-MM-DD
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Injured Party Information

Provide detailed information should follow up be needed.

Involved party 1

Additional Information

This field is required.
What type of medical assistance was rendered?(Required)
This field is required.
Was there physical injury? If so, what type of injury?(Required)
This field is required.
This field is required.
Were safeguards in use when injury occurred?(Required)
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This field is required.
Was the supervisor notified?(Required)
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This field is required.
Were there any witnesses?(Required)
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This field is required.

Supporting Documentation

SUPPORTING DOCS SECTION TEXT 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission