Last Revision: 11/28/2023


Form Instructions

Time & Place of Accident/Incident:

Section 1

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

Section 2

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

Section 3

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

Section 4

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

Section 5

Describe incident facts in detail, including the following:

Section 6

Signature Required:

  1. The individual intending to file this claim needs to provide their hand-written signature
  2. Enter the date the form was signed
  3. Enter the name of the individual taking this report (if applicable)
  4. 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 A copy may be submitted to the College/Departmental Safety Officer or Commonwealth Campus Director of Finance & Business.

Image of Incident Form