EHS & Risk Management Student/Visitor Incident Report
For V
isitors and Students (in non-work related injuries)
State law requires that you be informed that you are entitled to: (1) request to be informed about the information collected about
yourself on this form (with a few exceptions as provided by law); (2) receive and review that information; and (3) have the
information corrected at no charge.
If you are a student or a visitor (involved in a non-work related injury), complete this form and FAX it to the EHS & Risk
Management at 409-880-7977 or e-mail this form to .
1. Status:
2. Date of injury/illness: (M/D/YY)
3. Time of injury/illness:
4. Name: (Last, First, MI)
5. Address:
a. Home Telephone#:
b. Work Telephone#:
6. Will medical attention be required for this injury/illness?
Yes No
7. Address or location where injury or exposure occurred.
Bldg #
or Street: City: State:
8. Specific location where injury or exposure occurred (e.g., stairs, dock, lab):
9. Nature of injury/illness (e.g., cut, sprain, illness):
10. Body part involved (e.g., left arm, right eye):
11. Cause of injury/illness (e.g., slip or fall, chemical, etc.):
12. How and why did this injury/illness occur?
13. Doctor’s Name, Address, & Telephone number
14. List of witnesses and statements: (Use additional sheet(s) if necessary)
15. Contact information (if filled out by other than the injured party)
Name: Telephone#:
Date sent to EHSRM:
EHSRM Visitor/Student Injury Report Form v 1.0
For assistance regarding completion of this form contact Office of EHS & Risk Management.