University Incident Report Form Page 2
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2INCIDENT REPORT CONTINUED…
Action Taken and Treatment Provided:
Who was contacted about Incident?
911
DPS
Supervisor
Sports Med
EHS
Sup. Name:
Was treatment for an injury issued by staff?
YES
NO
REFUSED (Signature):
Treatment provided (please circle any that apply):
CPR
AED
ICE
Other (please describe):
Further Action Taken (clean-up):
YES
NO
Was the person transported away from activity?
EMERGENCY ROOM
SPORTS MED
STUDENT HEALTH SERVICES
HOME
DPS
If so, where was the person taken?
REFUSED TRANSPORTATION
Signature:
Description of Incident or Injury:
Injury Details:
Location of Injury On-Person Description:
- Please indicate on chart below, as well:
What was the Cause of Injury?
Animal
Chemical
Collision
Door
Drugs
Electrical
Explosion
Cutting Object
Fall
Fight
Fire
Hot Liquid
Kick
Falling Object
Running into Object
Lifting
Poison
Weapon
Thrown Object
Other:
What was the Nature of the Injury?
Abrasion
Bite
Bruise
Burn
Chip
Choking
Concussion
Cut
Dislocation
Drowning
Fracture
Laceration
Poisoning
Puncture
Scald
Scratch
Seizure
Severed
Shock
Stroke
Wound
Sprain/Strain
Other:
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Parent category: Business