Fillable Incident Report (Towson University)

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Incident Report (Towson University)

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File type: PDF

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Environmental Health & Safety
Incident Report
INFORMATION 1-13
1.Victim's Name (Firm Name if Business) LAST, First, Middle
2. Social Security No. or TU ID#
3. Address City - State - Zip Code
4. Telephone
5. Employer/School or Local Address
6. Employer/School/Local Phone Number
7. INCIDENT
8. Date and Time Occurred
9. Location of Incident Address
10. Hospitalized?
Yes No
11. Transported to Hospital? Yes No
12. Injuries/Illness Sustained
13. Work Related
Yes No
ADDITIONAL INFORMATION - WITNESSES 14-21
14. Name (Last, First, Middle)
15. Home Phone
16. Address
17. Business Phone
18. Name (Last, First, Middle)
19. Home Phone
20. Address
21. Business Phone
22. NARRATIVE: 1) Continuation of above item(s) - (indicate item no.) (2) Describe details of incident
23. Victim's Signature
If you are a TU Employee and the accident occurred during work (work related injury/illness) you must fill out the "First Report of Injury". “First
Report of Injury form” is located on the Office of Human Resources website at http://www.towson.edu/adminfinance/hr/benefits/summaries.asp under
“Miscellaneous Forms and Documents”. Submit the “First Report of Injury Form” to the Department of Human Resources within 24 hrs. of the
incident.
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Environmental Health & Safety is located in the Public Safety Bldg. Please complete the Incident Report (signature required) and return the form to
EH&S. Address: Towson University; Department of Environmental Health & Safety; 8000 York Road; Towson, MD 21252/fax 410-704-2993. For
information on how to file a claim with the State Treasurer’s Office, contact the Insurance Administrator, Department of Environmental Health &
Safety 410-704-6377.
25. NARRATIVE (CONTINUED)
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Incident Report (Towson University)

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Completed 27 July 2020

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