Incident Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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First name of Campus Recreation staff

Last name of Campus Recreation staff

Contact phone number for Campus Recreation staff

Email address of Campus Recreation staff

Role of Campus Recreation staff

Is there any other important information regarding the injury/incident?

First name of injured person

Last name of injured student

Contact phone number for injured student

Email address for injured student

Select the type of activity that was happening when the injury occurred

Describe the injury/incident

Was a Trainer seen?

If yes, what did the trainer say?

If no, did EMS/Fire/Police/911 respond?

Did the injured person refuse treatment?

If first responders came on scene, what services were provided?

If first responders came on scene, did the injured/individual refuse transport?

If the injured/individual accepted transport by first responders, which hospital were they taken to?

Where did the injury/incident happen?

If Off Campus Trip, please provide city, state and purpose of trip

Any additional location details (Court #, Field #, etc...)

Activity

If other, please give details of the activity

Were there any first-hand witnesses willing to provide a brief description, if needed?

If yes, please provide witness full name, contact phone number, and email address

If there was a second witness, please provide their full name, contact phone number, and email address

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