Fillable Student Or General Public Injury And Property Damage Report Form printable pdf download

Student Or General Public Injury And Property Damage Report Form

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TRUMAN STATE UNIVERSITY

STUDENT OR GENERAL PUBLIC INJURY AND PROPERTY DAMAGE REPORT

(DO NOT USE FOR VEHICLE ACCIDENTS)

INSTRUCTIONS: Accidents and incidents resulting from, arising out of and directly relating to the University's premises (owned,

rented or leased) and operations are to be reported on this form, provided the accident or incident caused (a) bodily injury to or the

death of any person or (b) damage to property owned by any person. In the event the accident caused bodily injury to or the death of

any person, the Department of Public Safety shall be notified by telephone immediately.

This form shall be submitted by (1) The academic staff member in charge of the student's activities at the time of the accident or

incident or to whom the accident or incident was reported; or (2) the person in charge of the building or facility or the person

sponsoring the meeting or event attended by the student or general public at the time of the incident. The Department of Public Safety

is available for consultation and guidance in completion of this form.

This form shall be TYPED with original only, signed by the person submitting the form and forwarded to the Controller's office WITHIN

48 HOURS AFTER THE ACCIDENT OR INCIDENT. This report is intended solely for internal use by the University and the Office of

the General Counsel. In completing the report below, "accident" and "incident" will be referred to as "occurrence." The name to be

indicated in Item 5 shall be the name of the person who sustained bodily injury, had property damaged or alleges to have sustained

Personal Injury. *There is a blank page at the end of this form if you need additional space for information.

1. DATE OF REPORT

2. DATE OF OCCURRENCE

3. TIME OF OCCURRENCE

_____ : _____

4. PLACE OF OCCURRENCE (name of bldg., room no., or describe University property)

5. FULL NAME OF INJURED OR AGGRIEVED PERSON

6. TELEPHONE

7. SEX

8. AGE (actual or apparent)

MALE

FEMALE

9. ADDRESS (if student give campus address)

10. MARRIED

11. STATUS

YES

STUDENT

PUBLIC

12. DESCRIBE DETAILS OF THE OCCURRENCE INCLUDING YOUR OPINION AS TO HOW BODILY INJURY, PROPERTY DAMAGE OR PERSONAL INJURY OCCURRED AND

HOW YOU OBTAINED THE INFORMATION. ATTACH COPIES OF ANY CORRESPONDENCE, POLICE REPORTS OR ANY OTHER INFORMATION AVAILABLE WHICH MIGHT

ASSIST IN THE INVESTIGATION OF THIS OCCURRENCE.

13. DESCRIBE FULLY THE SPECIFIC PART OF THE BODY INJURED AND NATURE OF INJURY. INDICATE WHETHER THE INJURED PARTY WAS HOSPITALIZED.

14. DESCRIBE DAMAGE TO PROPERTY OF OTHERS AND ESTIMATE COST TO REPAIR OR REPLACE PROPERTY.

CONTINUED ON NEXT PAGE

11-21-08

Student Or General Public Injury And Property Damage Report Form

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