Free Incident Report Template 55
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THE UNIVERSITY OF ALABAMA AT BIRMINGHAM

INCIDENT REPORT FORM
(Incidents involving employees, students, visitors)
This is a confidential report and should not be made a part of an employee's personnel record. It is completed
to allow us to obtain advice from legal counsel and for the protection of the university and it's employees from potential liability.

******** PLEASE PRINT LEGIBLY *********
INFORMATION ABOUT THE PERSON INVOLVED IN THE INCIDENT:
Full Name:

Last 4 SSN#:

Home Address:

Gender:

Employee: Full-time Part-time

Permanent Temporary

Date of Birth:

Home phone:

Student: SOM

SON

SOD Other

M F
Visitor:

Campus Phone:

Campus address:
Job Title:

Supervisor:

INFORMATION ABOUT THE INCIDENT:
Date of Incident:

Time:

Police notified: Yes

No

Case #:

Location of Incident:
Describe what happened, how it happened, factors leading to the event, substances or objects involved. Be as specific as
possible (attach separate sheet if necessary):

Were there any witnesses to th