INCIDENT FORM INSTRUCTIONS
Systems and Procedures
A Division of The Corporate Controller's Office
IN
Last Revision: 06/01/2022

INCIDENT FORM

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 either their hand-written signature or provide their digital id
  2. 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
  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 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.

Image of Incident Form