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.

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 website contains 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:

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). 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.

Accessing GURU Forms:

GURU PDF forms are designed for use with Adobe Acrobat Reader or Adobe Acrobat Pro. Each browser (Chrome, Firefox, Internet Explorer, Microsoft Edge, 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 examples, Nuance). It has been brought to the attention of the Office of Systems and Procedures that PDF forms do not function appropriately when accessed using Firefox and/or Microsoft Edge. In order to access any of the forms on GURU and have the fill-and-print functionality work properly, the end-user must access the GURU website using Google Chrome.

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.

Web-based Documents:

Clicking the form download icon on any of the form instruction pages on GURU will open a web-based version of the form. While it appears to have fill-and-print fields available, not all functionality may be available for use (i.e. digital ID fields). With some exceptions (see below), it will be necessary to convert these web-based documents to PDF documents.

Converting Web-based Documents to PDF Documents:

In order to have a version with all PDF capabilities enabled, click the "Fill & Sign in Acrobat" or "Open with Acrobat" icon located in the upper right-hand corner of the screen. This icon must be clicked before entering any information. A new versions of the document will open. Complete this version and save the document in a location where you will be able to locate it.

If, upon opening the PDF in Google Chrome, the Fill & Sign in Acrobat icon does not appear in the upper right-hand corner of the screen, it will be necessary to enable Adobe Acrobat extension. Please visit Enable Adobe Acrobat extension for Google Chrome for instructions to enable Adobe Acrobat extension.

Exceptions:

Combining PDF Documents:

There may be times when it is necessary to combine multiple PDF documents into a single document for submission. In those instances, complete the following steps:

Repeat this process for each document that will be combined (each file name must be different from the previous (i.e. incident-form-smith-josephA, incident-form-smith-josephB)

Applying Digital ID's on PDF's (general instructions):

This form has the Digital ID (applying an electronic signature to the document) process enabled. If, upon opening the PDF in Google Chrome, the following does not appear in the upper right-hand corner of the screen, it will be necessary to enable Adobe Acrobat extension

Image of Adobe Acrobat Fill-and-Sign bar

Please visit the following for instructions to enable Adobe Acrobat extension:

Enable Adobe Acrobat extension for Google Chrome

Complete all fill-and-print form fields before completing the signature process:

  1. Open the Incident Form
  2. Before entering any information, click the "Fill-and-Sign in Acrobat" (see above) icon or click the "fill-and-sign" option (looks like a pen nib) located on the right-hand column within Adobe Acrobat, or click "Tools" from the tool bar on the upper left-hand side of the screen and click "Open" under the Fill & Sign option
  3. Complete all fill-and-print fields
  4. Once the form is complete, click in the signature form field and either:
    • select your digital ID and click continue, or
    • create your digital ID, select your digital ID, and click continue
  5. Review the information in the appearance box and click sign
  6. You will be required to save a copy of the document (the digital signature is not applied until the form is saved)
    • A pop-up window opens with the file name containing incident-form in the File name field. Add the last name, a dash, and first name of the individual involved in the incident (i.e., incident-form-smith-mary)
    • Select a location where you will be able to retrieve the document
    • Click Save
  7. Close the form version appearing on your screen
  8. Open the version saved in the previous steps
  9. Verify that the digital ID appears on the document
  10. Close the document

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
Document: Ultimate Distribution: Retention Periods: Disposition:
Original (Paper or Electronic) Claims Supervisor, Office of Risk Management End of fiscal year +2 years Paper document - Secure Bin disposal or shred

Electronic document/data - delete and empty recycle bin

Where to Send Completed Forms:

Forward to Claims Supervisor, Office of Risk Management.

Contact Information:

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

Cross References:


(2021Aug20)