Incident/Accident Report Incident

This form is used to report injuries, exposures, near misses, and unsafe conditions.

It is not an investigation document. EH&S will determine follow-up actions.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Name* Required

Additional Location Details

Exact Location

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Role

Department/School

NETid

Date of Incident

Was this incident work-related?

Person(s) Affected (if different than reporter)

Supervisor / PI (Principal Invesitigator)

Name of injury or exposure

Body part(s) affected

First Aid provided?

Medical treatment required?

Location of treatment (if applicable)

Describe any immediate actions taken

Supervisor / PI Acknowledgement (If Applicable)

Add files to upload as supporting documentation along with your incident.