Student Injury/Illness Reporting Form

This information will be used by EHS (Environmental Health and Safety) to follow up on student injury/illnesses that may have resulted from an uncontrolled hazard. This reporting tool is intended only for students that do not have "employee" status and which have not filed for workers compensation benefits, as described in the EHS SOP, On the Job and Student Injuries.

Injured/Ill Student Details

Student NUID Required

Student Name Required

Email Address Required

Contact Phone Number

Incident Submitter Details

Is incident submitter different from student information provided above? Required

Yes

Submitter Name Required

Submitter Email Address Required

Submitter Phone Number Required

Incident Details

Incident Date Required

Year

Month

Day

Time of Incident Required

New Hour

New Minute

Location of Incident Required

Name of Responsible Faulty/Staff for Area

Describe the Nature of your Injury/Illness Required

Brief Description of what Caused the Injury/Illness Required

What might have Prevented this Injury/Illness Required

Additional Information/Comments

Leave this field blank