- Time & Place of Accident/Incident - Complete for all accidents/incidents. Indicate in the appropriate spaces the time and place of the accident/incident.
- Property Damage - For accidents/incidents with property damage. Indicate the name, address, and telephone number of person who owns the damaged property.
- Injured Person - For accidents/incidents with injured persons, indicate the name, street address, telephone number, city, state, zip code, and occupation of the injured person(s). Also indicate the name of the injury, and where the injured person was taken for examination.
- Witness - Complete for all accidents/incidents. Indicate the names, addresses, and phone numbers of all witnesses.
- Describe Incident Facts in Details - Complete for all accidents/incidents. The individual intending to file this form should describe the facts of the accident/incident in detail. A separate sheet of paper may be used. 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 individual intending to file this claim needs to provide either their hand-written signature or provide their digital id
- If the individual intending to file this claim provides a hand-written signature, select the date this form was signed. If a digital ID was provided, skip this field
- Enter the name of the individual taking this report (if applicable)
- If the report was completed by someone other than the individual intending to file the claim, select the date they completed the form
The completed and signed form should be turned into the College/Departmental Safety Officer or Commonwealth Campus Director of Finance & Business, who will file it with the University's Office of Risk Management.