Incident Report Form
Office of Equal Employement Opportunity & Risk Administration
 
 
Involved Person:
First Name: Middle Name: Last Name:
   
Phone:  Email:  S Number:
- -
   
Address:  City:  State:  Zip:
    

Are you submitting this report on behalf of someone else? 

Classification:
 

Location:

Conditions of Accident (e.g. weather, apparent hazards, lights on/off, dry/wet, etc.)

What Happened (Summary of events leading up to the injury)

Witnesses:
Name Phone Email
- -
- -

Others Involved:
Name Phone Email
- -
- -

Police Contacted?
Risk Management Contacted?

Illness or injury Involved?     


  Vehicle(s) Involved? 

  Property Involved? 

  Club Activity? 

Minor Involved?