Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

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Incident Date

Date Occurred

Supervisor Notified - Date

Supervisor Notified - Time

Employee Information

Employee Name: First and Last

Home Address

City, State, Zip

E-Mail Address

Home Telephone

Work Telephone

Sex

Birth Date

Employment Information

Employee's Job Title

Department Name

Hire Date

Employee's Status

Hours Typically Worked: Monday

Hours Typically Worked: Tuesday

Hours Typically Worked: Wednesday

Hours Typically Worked: Thursday

Hours Typically Worked: Friday

Hours Typically Worked: Saturday

Hours Typically Worked: Sunday

Supervisor's Name

Supervisor's Daytime Phone

Supervisor's Email Address

Incident Information

Description of Incident

What was employee doing when incident occurred?

Apparent Cause of Injury

Body Part Affected

Body Part Position

Identify Harmful Object or Substance

Witness Name

Witness Home Phone

Did Employee Return to Work?

If Not, Last Day/Date Worked

Time Employee Began Work (AM - PM)

Time Employee Stopped Work (AM - PM)

Injured on Georgetown University Premises

Medical Information

Employee Treated in Emergency Room?

Hospitalized Overnight as Inpatient?

Employee Treated By Healthcare Provider?

Healthcare Provider’s Name

Healthcare Provider’s Address and Phone

Hospital Name and Address

Type of Transportation to Medical Facility

Add Supporting Documents

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