Life @ Otis : Staff Life

Incident/Injury Report



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(* indicates a required field)

Reporter/Observer Information

* Reported By:
Injured/Victim
Observer/Reporter
* Name of Individual Reporting:

Faculty
Staff
Student ID:
Visitor/Guest
Other

* Reporter Phone:
* Reporter Email:

Injured/Victim Information

* Name of Injured/Victim:
Faculty
Staff
Student ID:
Visitor/Guest
Other

* Injured Phone:
* Injured Email:
* Injured Address:

Nature of Incident

(* Select all that apply)
Injury
Theft
Assault
Car Damage/Vandalism
Property Damage
Other

* Date of Incident:
* Tiime of Incident:
* Location of Incident:
Please be as specific as possible including building, floor, area, etc.

* Details of Incident:
Please describe in your own words what happened in as much detail as possible. If applicable, describe any property damage/loss.


Individuals Involved:
This may include witnesses.
Name: Phone:
Name: Phone:
Name: Phone:

Was Action Taken?
No
Yes
If yes, please describe what action and by whom


Did the Police Respond?
No
Yes
Arrival Time:
Officer Name:
Badge #:

Did the Fire Department Arrive?
No
Yes
Arrival Time:

Did Paramedics Arrive?
No
Yes
Arrival Time:

Was First Aid Administered?
No
Yes
By Whom:

 

 

 

 

Related Content:

Incident Report FAQ (PDF)