Non Employee Incident Report Page 2
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2Non-Employee Injury / Incident Report
Use this form to report incidents involving Students or Visitors involved in an
Injury or Incident on campus.
To report a UNC employee injury/incident, report to Human Resources and fill out an Injury/Illness report form.
STUDENT/VISITOR INFORMATION
Section I
Name
Bear # (if available)
Home Address
City
State
Zip Code
Which applies to you:
Sex:
Home Phone
Cell Phone
Student
Visitor
Male
Female
INJURY / INCIDENT INFORMATION
Section II
Injury or Incident Date
Injury or Incident Time
Was the incident on UNC’s property?
AM
PM
YES
NO
Location of Incident (Room #, Building, Parking Lot)
Was incident reported to a UNC Faculty or Staff member?
YES
NO
If Yes, provide name of UNC personnel:
Was UNC Police Department Notified?
What were you doing when incident occurred?
YES
NO
Attending Class
Attending Event
Other_________________
Immediate Action Taken (Check all that apply)
First Aid Provided
Went to Doctor
Went to Hospital
Went to Student Health Center
Other________________________________
YES
NO
Did the individual go to the hospital, student health center, etc., because UNC personnel advised them to go?
If Yes, who was the UNC
Nature of Injury (Identify how the injury or incident occurred; include the part(s) of the body affected. Add additional page if necessary).
personnel____________________________________________________________________________________________
Name the object or substance which caused the injury or incident to occur.
List all known witnesses
(include Name and Phone Number)
Student/Visitor Signature
Date
Name of Reporting Party (Print Name)
Phone Number
UNC Affiliated
YES
NO
Send original form to Environmental Health & Safety – Campus Box 57
Section III
Environmental Health & Safety Use Only
Date EHS Received Report
UNC Police Report Number (if available)
EHS Comments
Departments Notified of Incident
UNC Police Department
Dean of Students
Human Resources
Facilities Management
Risk Management
Other________________________________
Departments should keep a copy for their records
11/2013 - EHS
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