Report • CampusOptics

Please complete this form within 24 hours for any incident that could have resulted in an injury. If you were injured, please do not fill out this form. Instead, complete the Accident Injury/Occupational Illness Request Form.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

Loading…

General Information

Date of Incident

Time of incident

Location of Incident (Building, Room, etc)

Detailed Description of the Incident

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

What could be done to correct this?

Involved Person/Persons Information

Involved Persons Name ( First and Last)

Involved Persons Phone Number

Involved Persons Email

Involved Persons GU ID#

Involved Person's Department

If other, please describe.

Involved Persons Supervisor (First and Last Name)

Supervisor's Email

Was Supervisor Notified

Witness/Witnesses Information

Reporting person is the same as involved person

Were there any witnesses?

Witness/Witnesses First and Last Name

Date incident reported

Time incident reported

Investigation Section

Incident Status

EHS NOTES

Incident Closure Date

Add Supporting Documents

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