Fillable INJURY/PROPERTY DAMAGE REPORT (Michigan State University)

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INJURY/PROPERTY DAMAGE REPORT (Michigan State University)

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RMI\WEB SITE\Forms\Injury Property Damage Report.doc Revised 9/13
INJURY/PROPERTY DAMAGE REPORT
Office of Risk Management & Insurance
Olds Hall
408 W. Circle Drive Rm 113
East Lansing, MI 48824
Phone (517) 355-5022
E-mail: riskmgmt@msu.edu
Please PRINT or TYPE THIS FORM IS A CONFIDENTIAL – INTERNAL DOCUMENT TO BE COMPLETED BY MSU EMPLOYEE
TIME
Date/Time of Incident
Location: Street, City, MSU Bldg. Rm #
& PLACE
Type of Premises
Conditions
Reported to Police Dept.:
PREMISES
Construction Site
Parking Lot
Uneven Surface
Report Number:
CONDITION
Hallway
Sidewalk
Other:
Lobby/Entrance
Stairway
Office
Street
Not Reported
Other:
DESCRIBE WHAT HAPPENED:
INCIDENT
DESCRIPTION
NAME
AGE
PHONE #
INJURED
PERSON
ADDRESS
INJURY - Describe the type, severity, and body part involved
DESCRIPTION
OF INJURY
Was Medical Treatment Given? Yes No
Will seek treatment later
Name of Medical Facility/Doctor
Transported by Ambulance
Transported by Other:
PROPERTY
OWNER’S NAME
ADDRESS
PHONE #
DAMAGE
Describe the property and the damage
Estimated
Repair/Replacement Cost
WITNESSES
NAME
ADDRESS
PHONE#
GIVE THE FULL
NAME & ADDRESS
OF EACH WITNESS
NAME/TITLE OF MSU
EMPLOYEE COMPLETING THIS REPORT:
PHONE: E-MAIL:
MSU DEPARTMENT:
DATE :
NAME/TITLE OF MSU EMPLOYEE’S SUPERVISOR:
PHONE: E-MAIL:
SUPERVISOR’S SIGNATURE:
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INJURYPROPERTY DAMAGE REPORT (Michigan State University)

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Completed 8 February 2022

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