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 Address* 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

Injured Person Phone Number

Injured Person Email

Injured Person Affiliation with the University

GU ID#

Department/Division

Name of Supervisor

Phone Number

Email Address

Title/Position

Accident Information

Occurred At

Location of Incident (Building, Room, etc)

Injury Narrative

What was the victim involved in on campus?

To Whom did you report this incident?

Date incident reported

Time incident reported

List any witnesses

Part(s) of the body injured

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?

Additional Information

Was Gonzaga Campus Security Notified?

Was 911 called?

Did an ambulance respond?

Was the victim transported to the hospital?

If transported, which hospital?

Will employee miss work

Do you plan to pursue L&I

Additional information or recommendations

Completed to the best of my knowledge

EH&S Manger

Do you have any additional information to provide?

Recommendation for prevention, follow up or training?

Corrective action taken

Insurance Contacted

Claim # (if applicable)

Incident Status

EHS NOTES

Incident Closure Date

Reportable to Worker's Comp

Add Supporting Documents

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