Environmental Health and Safety

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

This form is best viewed on a desktop computer.

Please follow these instructions for this form:

Fill out form and check the information for errors.
If the form is correct, click the submit button below. A copy of the report will be sent to the email address provided in Preparer's Email Address section.
Alternatively, you may also Print and FAX a SIGNED copy to EH&S Department at 745-5037.

DOWNLOAD PRINTABLE FORM HERE.

If you see this don't fill out this input box.

* Name: (Last, First, M.I.)

WKU Student?

Yes

* Local (home) Address:

Home Phone:

Student/Visitor Email Address:

Visitor?

Yes

* Date of Accident:

* Time of Accident:

This accident/incident occurred:

On Campus

Off Campus

* Specific location of accident:

* Activitiy in which the person was engaged in at the time of the accident:

* Equipment, materials, apparatus, etc., you were using at the time of the accident:

Property damage: (please describe if any)

Witness(es) if any:

Witness(es) phone number:

Initial Medical Treatment:

Nature of Injury:

Body Part Injured:

Hold down the CTRL key (Command ⌘ on Mac) to select multiple options.

* Details of accident:

* Preparer's Email Address:

A copy of this report will be sent only to the Preparer.

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