INCIDENT FORM

Table of Contents:

• Purpose
• General Information
• Exhibit and Instructions
• Form Requirements
• Number of Copies and Ultimate Distribution
• Where To Send Completed Forms
• Contact Information
• Cross References

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Purpose:

The Incident Form provides a means for the Claims Manager within the Office of Risk Management to obtain factual information to evaluate claims for property damage or bodily injury accidents or incidents.

General Information:

DO NOT use this form for worker's compensation claims (see Human Resources Workers' Compensation website) or for automobile accident/injuries claims (see Vehicle Accident Report). Each of those websites contain documentation related to those types of events.

Complete the form, in its entirety, and describe the incident in detail. The individual intending to file the incident form must sign and date the completed form. If the individual is unable to complete the form, a University representative may assist with completion of the form, but the form must be signed by the individual.

The completed and signed form is to be turned into the College/Departmental Safety Officer or Commonwealth Campus Director of Finance & Business, who will file the report with the University's Office of Risk Management.

Exhibit and Instructions:

For step-by-step instructions for completing the Incident Form, 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 Associate Vice President for Budget and Finance). Policy FN17 Required Use of Approved University Forms Appearing in the General University Reference Utility (GURU) requires that all form templates must be vetted and approved prior to being published on the GURU website and all such documents having gone through said established approval process must be password protected. See Procedure FN2017 Use of Forms Appearing on the GURU Website for complete details.

If you encounter any difficulties, contact the GURU support staff by submitting a Technical Support Form request.

Number of Copies and Ultimate Distribution:

Where to Send Completed Forms:

Forward to the Office of Risk Management Claims Supervisor at psuclaims@psu.edu.

Contact Information:

For questions or additional details, please contact the Office of Risk Management.

To request changes to this form, please contact the Office of Systems & Procedures by submitting a GURU Technical Support Request Form.

Cross References:

• Policy AD35 University Archives and Records Management
• Policy FN17 Required Use of Approved University Forms Appearing in the General University Reference Utility
• Procedure FN2017 Use of Approved Forms Appearing on the GURU Website

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