Report • CampusOptics

DO NOT COMPLETE IF INJURED WHILE WORKING IN A STUDENT WORKER CAPACITY. STUDENT WORKERS SHOULD COMPLETE A SEPERATE REPORT. Please complete this form in its' entirety to report an injury, near miss, or accident.

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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Injured Person Contact Information

Injured person's First and Last Name

Injured Person's Phone Number

injured Person's Email

GU ID#

Injured Person's Affiliation with the University

Incident Information

Type of Incident* Required

Please describe other* Required

Occurred At

Location of Incident (Building, Room, etc.)

What was the victim involved in on campus?

If other, please describe.

Was Gonzaga Campus Security Notified?

Was the victim transported to the hospital?

Was 911 called?

Did an ambulance respond?

If transported which hospital?

Did you report this incident to anyone else? If so, who?

List any witnesses

Part(s) of body injured

Will you seek medical treatment

Date incident reported

Time incident reported

Incident narrative

Additional Information

Additional information

Incident Status

Date incident closed

Insurance Contacted

Claim #(if applicable)

Notes

Add Supporting Documents

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