Free Incident Report Template 56
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NON-EMPLOYEE INCIDENT REPORT
Person(s) involved:
NAME:
ADDRESS:
CITY:

STATE:

ZIP CODE:

Affiliation with University: Student

Visitor

Incident Date:

Time:

Campus:

PHONE:

AM

PM

Incident Location:

Full Description of Incident:

Witness(es): Name:
Address:

Name:
Address:

City/State/Zip:

City/State/Zip:

Phone:

Phone:

Medical Treatment?

Yes

No

Treatment Refused?

If yes, transported for treatment by whom?
Diagnosis and type of treatment (if known):

Signature of Student/Visitor involved in incident (if available):
University Employee reporting the incident:
Employee’s Title:
Send copies within 24 hours to:

Date Reported:
General Counsel, 2nd Floor Library, fax: 2-7821
Elaine Ramhoff, Compliance and Risk Management, 310 Harbourt Hall, fax: 2-3662
Compliance and Risk Management
Environmental Health & Safety * Kent, Ohio 44242-0001
Phone: (330) 672-9565 * Fax: (330) 672-3662
Revised Mar 2013