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:   -- Please Select -- Abrasion/Scratch Allergic Reaction Amputation Asphyxiation/Strangulation/Drowning Asthma Bite/Sting By Animal/Insect Burn Cardiovascular Disorder Chipped/Broken Teeth Contusion/Bruise Crushing Injuries/Compression Dermatitis Dislocation Dizziness/Disorientation Electrical Shock Exposure Foreign Body/Foreign Substance Fracture Frostbite/Hypothermia Gunshot Headache Hearing Loss Heat Stroke/Exhaustion Infectious And Parasitic Disease(s) Irritation Laceration/Cut Loss of Consciousness Multiple Injuries Nausea Pain Poisoning Puncture Respiratory Disorder Sprain/Strain      Other:
Body Part Injured:   -- Please Select -- Abdomen Ankle Arm(s) Back/Spine Chest Clavicle Ear(s)-Auditory System Elbow(s) Eye(s) Face Finger(s) Foot/Feet Hand(s) Head Heart-Cardiovascular System Hip(s) Knee(s) Legs(s) - Calf/Thigh Mouth - Tounge/Lip(s) Multiple Parts Neck Nose Respiratory System Rib(s) Shoulder(s) Skin Throat Thumb(s) Toe(s) Tooth/Teeth Whole Body Wrist      Other:
Details of Accident:
Initial Medical Treatment:   -- Please Select -- No Medical Treatment First aid only Treatment at WKU Health Services or clinic Emergency Room       Other:

 

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