INCIDENT FORM

Form Instructions

Time & Place of Accident/Incident:

Section 1

Select the date of accident/incident
Enter the time of accident/incident, including AM or PM
Enter the location of accident/incident (i.e., street name or intersection)
Enter the city where accident/incident occurred
Enter the state where accident/incident occurred
Enter the zip code of accident/incident location
Enter the name of the University Campus

Property Damage - For accidents/incidents with property damage indicate the following:

Section 2

Enter the name of the owner of property sustaining damage
Enter property owner's telephone number, including area code
Enter the street address of the property sustaining damage
Enter the city of the property sustaining damage
Enter the state of the property sustaining damage
Enter the zip code of the property sustaining damage
Enter the property owner's email address
Provide a description of property damages

Injured Person - For accidents/incidents with injured persons, indicate the following:

Section 3

Enter the name of injured person
Enter age of injured person
Enter the street address of injured person's mailing address
Enter the city of injured person's mailing address
Enter the state of injured person's mailing address
Enter the zip code of injured person's mailing address
Enter the email address of the injured person
Enter the injured person's telephone number, including the area code
Enter the occupation of the injured person
Enter the nature of injury sustained by injured person
Enter the name of medical facility to which the injured person was taken

Witness - Complete the witness information for all accidents/incidents, including the following:

Section 4

Enter the name of 1st witness
Enter the complete mailing address of 1st witness
Enter the telephone number, including area code, for 1st witness
Enter the name of 2nd witness
Enter the complete mailing address of 2nd witness
Enter the telephone number, including area code, for 2nd witness

Factors - Complete for all accidents/incidents, including the following:

Section 5

Premises - select the appropriate factor from the drop-down list. Options include dry, wet, snow covered, icy, or other
If other selected in previous field, provide a description of the premises
Surface - select the appropriate surface from the drop-down list. Options include concrete, asphalt, metal, carpet, tile, or other
If other selected in previous field, provide a description of the surface
Lighting - select the appropriate lighting factor from the drop-down list. Options include indoor-on, indoor - off, outdoor- sunny, outdoor - overcast, or other
If other selected previous field, provide a description of the lighting

Describe incident facts in detail, including the following:

Section 6

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.

Signature Required:

The individual intending to file this claim needs to provide their hand-written signature
Enter the date the form was signed
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 must be submitted to psuclaims@psu.edu. A copy may be submitted to the College/Departmental Safety Officer or Commonwealth Campus Director of Finance & Business.