Western Kentucky University

Environment, Health and Safety

Accident/Incident Report Form for Non-employees
     (including Students and Visitors)

Please follow these instructions for this form:

  1. Fill out form and check the information for errors
  2. If the form is correct, click the submit button below. For security reasons, this form can no longer be sent to you via e-mail.
  3. After submitting the form, a printer-friendly copy will display that you may print for your records.
  4. Alternatively, you may also Print and FAX a SIGNED copy to EH&S Department at 745-5037

PERSONAL INFORMATION

Name: (Last, First, M.I.):   Home Phone:  
Local (Home) Address:
    
WKU Student?  Yes    No
Visitor?  Yes    No

 

ACCIDENT INFORMATION

Date of Accident:   Time:   This accident/incident occurred:  On Campus     Off Campus
Specific location of accident:  
Activity in which the person was engaged at the time of the accident:  
Equipment, materials, apparatus, etc. that the person was using at the time of the accident:  
Property Damage:  
Witness(es):   Witness phone number(s):  
Nature of Injury:       Other:  
Body Part Injured:       Other:  
Details of Accident:
    
Initial Medical Treatment:        Other:  

 

SUBMITTED BY

Filer/Preparer's Name:   Title:  
Phone:   E-mail address:   Date Filed:  

 

 

 Last Modified 7/22/13