ACCIDENT/INCIDENT REPORT FORM

University staff and students who are involved in an incident should inform their supervisor
of the incident immediately. This Accident Report Form must be completed and submitted to
the Chief Security Officer’s office within 24 hours. Please write legibly and provide as much
information as available at the time of submission.
I. Personal Information: (to be completed by injured individual)
Name of injured individual: __________________________________ Gender: Male /
Female
Home Address:
__________________________________City____________State_________
Home/Cell Phone Number: ______________________ Date of Birth: ____/____/____
Registeration Number#:________________ or Matric Number#:_______________________
Marital Status: __Married __Single __Separated __Widowed __Divorced
Position: __Staff __Faculty __Graduate Student __Undergraduate Student __Other
________
If student, did the incident occur as a result of your course of study or employment (please
underline one)
Position Title: _________________ Department: ________________Date of Hire: ________
Supervisor Name: ______________________ Supervisors Phone #:___________________

II. Incident Information: (to be completed by injured individual)

Date of Incident: ____/____/______ Time of Incident: ___________ AM PM
Time shift began: __________ AM PM
Location of Incident (Please be specific):_________________________________________
Source of Incident (tool, machine, substance etc…):_________________________________
Type of Injury (burn, fracture, cut etc…):_________________________________________
Injured body part(s):__________________________________________________________
Explanation of how the incident occurred:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Witnesses to the incident? Yes/No
If yes, names:________________________________________ Other injured parties?
Yes/No If yes, names:____________________________________________
Are relevant photos of incident/area/conditions available? Yes/No If yes, please provide
copies to CSO.

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Was medical attention sought? Yes/No If yes, Date: ___/___/___ Time: ________ AM
PM
If yes, name and address of medical provider: _____________________________________
Signature of Injured Individual: ________________________________ Date: ___/___/____
Signature of Supervisor: ____________________________________ Date: ___/___/______

III. Investigation Information: (to be completed by injured individual’s supervisor)

Describe in detail how the injury occurred:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
To whom was incident reported: _________________________________________ Date:
_____/_____/_____
Was the individual performing regular work activities when injured? Yes/No
If no, please explain: ______________________________________________________
What was injured person doing when the incident occurred?
___________________________
How were they doing it? _____________________________________________________
___________________________________________________________________________
Was injury a result of unsafe acts? Yes/No If yes, describe unsafe act in detail:
___________________________________________________________________________
___________________________________________________________________________
Was injury a result of unsafe condition(s)? Yes/No If yes, describe unsafe condition(s) in
detail:
___________________________________________________________________________
___________________________________________________________________________
Could this incident have been prevented? Yes/No What is the planned corrective action(s)?
___________________________________________________________________________
___________________________________________________________________________
Person responsible for corrective action: _________________________________________
Expected date corrective action will be completed: _____/_____/_____
Use this area to make any additional comments relative to this incident:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Name of person completing investigation (print):
____________________________________ Signature of person completing investigation:
______________________________________ Date investigation completed:
_____/_____/_______

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Completed Accident Report Forms must be dropped off at the CSO’s office within 24 hours
of when the incident occurred. Additionally, all Accident Report Forms are sent to the office
of the Dean.
Please complete both sides of this form