MARQUETTE UNIVERSITY
Campus Incident Report
Date: ___________________________________________________
Please fill out the following portion of this report in regard to the incident occurring on: ______________________________
Student: Yes No Visitor: Yes No
Program Participant (EOP, etc.): Yes No
(If an employee , please complete the Worker’s Compensation First Report of Incident)
Visitor Name: _________________________________________ Sex: M F Age: _________
Home Address: ________________________________________ Home Phone/Contact: _________________________
________________________________________
Date & Time Incident Occurred: ____________________________ Location: ____________________________________
What were you doing at time of incident? (Use additional page if more space is needed.)
How did the incident happen (Explain Fully)?
What caused the incident to occur?
Witnesses? List Names:
How could the incident have been prevented?
Medical attention sought? Yes No If yes, Doctor/Provider’s Name: _______________________________
If no, do you intend to seek medical attention in the future? Yes No
If injured, have you ever had a similar problem? Yes No
If yes, explain:
Have you previously received treatment for this condition? Yes No
If yes, Doctor/Provider’s Name: _________________________________________________________________
Employee Signature/Date:____________________________________________________________________________
NOTE: Please contact Department
of Public Safety for medical aid and
transport.
