Systems and Procedures
A Division of The Corporate Controller's Office
IN

INCIDENT FORM
FORM INSTRUCTIONS

Form Instructions

  1. Time & Place of Accident/Incident - Complete for all accidents/incidents. Indicate in the appropriate spaces the time and place of the accident/incident.
  2. Property Damage - For accidents/incidents with property damage. Indicate the name, address, and telephone number of person who owns the damaged property.
  3. 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.
  4. Witness - Complete for all accidents/incidents. Indicate the names, addresses, and phone numbers of all witnesses.
  5. 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.
  6. The form should be dated and signed by the individual who is intending to file the incident form. It should be turned into the College/Departmental Safety Officer or Director of Business Services, who will file it with the University Risk Management Office.
Image of Incident Form