Fillable REPORT OF INCIDENT OR ACCIDENT (California State University, Fresno)

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REPORT OF INCIDENT OR ACCIDENT (California State University, Fresno)

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1
REPORT OF INCIDENT OR ACCIDENT
(Non-University employee)
CALIFORNIA STATE UNIVERSITY, Fresno
ATTENTION: This form contains information relating to an injured individual’s health and must be used in a manner that protects the
confidentiality of the injured to the extent possible while the information is being used for safety and health purposes. This form must be
completed within 24 hours of receiving information of a university-related injury or illness and emailed to ehsrm@mail.fresnostate.edu or faxed to
559-278-1153.
IMPORTANT: Please go to http://www.csufresno.edu/adminserv/ehsrm/about/forms/az.html Accident or Incident Report (non-University
employee), to ensure that you are using the most current version of this form.
SECTION 1: UNIVERSITY RELATIONSHIP (SELECT ONLY ONE)
Student Volunteer Visitor Contractor Fresno State Police Report Made? YES NO
SECTION 2: INCIDENT TYPE (SELECT ONLY ONE)
Injury Illness Other (Vehicle, Near Miss, Dangerous Condition, Exposure Incident)
SECTION 3: INVOLVED PERSON’S INFORMATION
First Name:
Last Name: __________________________________________
M.I.:
Street Address:
City:
State:
Zip:
Cell Ph:
Email:
Male
Female
Under 18? YES NO
SECTION 4: INCIDENT DETAILS
Date of Injury/Illness: Time: AM/PM Location:
Reminder: Please fill out 2
nd
page/back page regarding description of incident.
Name(s) of Witnesses:
1. NAME (Last, First, M.I.)
ADDRESS (Street, City, State, Zip)
CONTACT TELEPHONE
2. NAME (Last, First, M.I.)
ADDRESS (Street, City, State, Zip)
CONTACT TELEPHONE
3. NAME (Last, First, M.I.)
ADDRESS (Street, City, State, Zip)
CONTACT TELEPHONE
If the incident resulted in an injury or illness, answer the following questions.
a) Did the individual receive medical treatment in an emergency room? YES NO
b) Was the individual hospitalized overnight as an in-patient? YES NO
c) Did the individual receive medical treatment beyond basic first aid? YES NO
SECTION 5: HOSPITAL/CLINIC INFORMATION
Name of Facility:
Address of Facility:
Treating Physician: Phone Number:
SECTION 6: REPORTING INDIVIDUAL
Reporting Employee's Name(Print or Type) Telephone
Reporting Employee's Department/Office Email Date
Please proceed to next page to continue completing form.
2
REPORT OF INCIDENT OR ACCIDENT
(Non-University employee)
CALIFORNIA STATE UNIVERSITY, Fresno
DESCRIBE THE INCIDENT (STATE ONLY THE FACTS). Attach additional sheet of paper if necessary.
What was the person doing just prior to, and at the time of the incident? What objects/conditions contributed to the incident?
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REPORT OF INCIDENT OR ACCIDENT (California State University, Fresno)

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Completed 28 January 2021

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