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Risk Management

Incident/Accident Report Form

To be completed for incidents involving injury or potential injury to employees, attendees, visitors and/or general public. All questions must be answered. If a question does not apply to you, please enter N/A in the answer box.

Name of injured person:

Date of birth: (mm/dd/yyyy)

Home address:

Home phone:

Work phone:

Details of Incident/Accident

Incident Date: (mm/dd/yyyy) Incident Time: AM/PM

Location:

Description of what happened:

Report what you think contributed to the incident/accident:

Was injured party taken to hospital or doctor?: Yes/No

If yes, name of facility (if no, enter N/A):

How injured party was transported (if not transported, enter N/A):

Type of injury (ex: cut, puncture, burn, slip and fall):

State body part injured: Right/Left

Witness to incident/accident (if no witnesses, enter N/A) - Name:

Address (if no witnesses, enter N/A):

Phone (if no witnesses, enter N/A):

Reported to security/police? (if no, enter N/A): Yes/No

Name of police department responding (if none, enter N/A):

Report prepared by: Phone (if none, enter N/A): Date (if none, enter N/A): (mm/dd/yyyy)

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