Incident Report • CampusOptics

Please complete this form in its' entirety to report an injury or occupational illness. Provide updates as a note.

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Injured Person Contact Information

Injured Person First and Last Name* Required

Injured Person Phone Number

Injured Person Email* Required

Injured Person Affiliation with the University* Required

GU ID#

Department

Name of Supervisor

Accident Information

Date of incident* Required

Time of incident* Required

Location of Incident (Building, Room, etc)* Required

Injury Narrative* Required

What was the victim involved in on campus?

To Whom did you report this incident?

Date incident reported* Required

Time incident reported* Required

List any witnesses

Part(s) of the body injured * Required

Will you seek medical treatment

Physician Name

Physician Phone Nmber

Actions, events or conditions that contributed to this incident (i.e. weather, machinery, etc)

What could be done to correct this?

Supervisor Information

Phone Number* Required

Email Address* Required

Title/Position

Verify exact location of accident/exposure

Is location the same as listed on employee report?

Will employee miss work

Additional information or recommendations

Completed to the best of my knowledge

Was Gonzaga Campus Security Notified?

Was 911 called?

Did an ambulance respond?

Was the victim transported to the hospital?

If transported, which hospital?

EH&S Manger

Do you have any additional information to provide?

Recommendation for prevention, follow up or training?

Corrective action taken* Required

Insurance Contacted

Claim # (if applicable)

Incident Status

EHS NOTES

Incident Closure Date

Add Supporting Documents

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