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.
Reset Form
Print Form
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)