INCIDENT FORM
Systems and Procedures
A Division of The Corporate Controller's Office
IN

INCIDENT FORM

Table of Contents:


Purpose:

The Incident form provides a means for the Risk Management Office to obtain factual information to evaluate claims for property damage or bodily injury accidents or incidents. DO NOT use this form for worker's compensation or automobile accident claims.

General Information:

This form should NOT be used for on-the-job injuries of PSU employees (see Employer's Report of Occupational Injury or Disease), or accidents/injuries involving an automobile (see Vehicle Accident Report ).

Exhibit and Instructions:

To view the exhibit for this document, click the link below:

Incident Form Exhibit

Form Requirements:

No form may be used that substitutes for an approved official University form without prior review and approval by the steward of the form/central office, as facilitated by the Office of Systems and Procedures (designated representative of the Corporate Controller). See Policy FN17 - Required Use of Approved University Forms Appearing in the General University Reference Utility (GURU) for full details.

GURU PDF forms are designed for use with Adobe Acrobat Reader or Adobe Acrobat Pro. Each browser (Chrome, Firefox, Internet Explorer, etc.) has a built-in PDF viewer making it the default PDF viewer without asking users. These built-in viewers do not necessarily support all features required for PDF forms. Similarly, many calculations are not supported by other stand-alone PDF readers (for example, Nuance). If you experience problems downloading or opening documents, right click on the link on the Forms Locator Screen, select 'Save Link As' (or similar language) and save the file. The document can then be opened in either Adobe Acrobat Reader or Adobe Acrobat Pro from the saved location.

The latest version of Adobe Acrobat Reader is available for free. Contact your IT support staff person for downloading assistance, if/as needed. If Adobe Acrobat Pro better suits your needs, contact your IT support staff person for purchasing and installation assistance.

If you encounter any difficulties, contact the GURU support staff by submitting a Technical Support form request or by calling the tech support line at 814-863-8592.

Number of Copies and Ultimate Distribution:

Table of distribution and retention of the Incident Form
Ultimate Distribution: Retention Periods:
Original White Risk Management Office Current fiscal year +2 years

Where to Send Completed Forms:

Forward to the Risk Management Office.

Contact Information:

For questions, additional detail, or to request changes to this form, contact Risk Management.

Cross References:


(02-14-05)