University Incident Report Form
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1
2UNC CAMPUS RECREATION INCIDENT REPORT FORM
G
Category:
Month
Day
Year
Incident
Injury
E
Date:
Type of Incident or Injury (fight, leg injury) :
N
E
R
Time:
Facility:
Ct or Field #
AM
PM
A
L
Program or Group:
IM Sports
Sport Club
Fitness
OEC / Expedition
Special Event
Rental Group
I
N
(Activity, League, Event or Group Name)
F
Was Property or Equipment Damaged?
YES
NO
Specify:
O
Name
PID:
V
(Print) :
Age:
Gender:
I
(Last Name)
(First Name)
(M.I.)
C
University Status:
FR
SO
JR
SR
GRAD
FAC/STF
GUEST
Other:
T
I
Local Address:
M
(Street Address, Apt #)
(City)
(State)
(Zip)
I
Permanent Address:
N
(Street Address, Apt #)
(City)
(State)
(Zip)
F
O
Phone:
Email:
Witness 1
PID:
W
I
Name:
Age:
Gender:
T
(Last Name)
(First Name)
(M.I.)
N
E
W1 Phone:
W1 Email:
S
S
Witness 2
PID:
Name:
Age:
Gender:
I
(Last Name)
(First Name)
(M.I.)
N
F
W2 Phone:
W2 Email:
O
Employee
Employee
E
Name:
Signature:
M
(Last Name)
(First Name)
(M.I.)
P
Supervisor's Notes, Further Action Taken & Recommendations:
L
O
Y
E
E
I
N
Month
Day
Year
Employee
F
Signature:
Date Filed:
O
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