Incident Report - Salem
NON-EMPLOYEE INCIDENT REPORT
Person(s) involved: (Repeat this section as needed on the back of this form.)
NAME _________________________________________________________________
ADDRESS ________________________________________________________________
_________________________________________________________________
PHONE (_____) _____________________________________________
Incident Date ___ Time AM __ PM __
Location ____________________________ Campus _____________
Affiliation with University: Student __ Visitor __
Full Description of Incident: ___________________________________________________________
Witness(es): Name _________________________________________________________________
Address ______________________________________________________________
Phone (____)_________________________________________________________
Name ______________________________________________________________
Address _____________________________________________________________
Phone (____)________________________________________________________
Medical Treatment? YES __ NO __ ___MEDICAL TREATMENT REFUSED?
If yes, transported for treatment by whom? ________________________________
Where was individual transported? _______________________________________
Diagnosis and type of treatment? ________________________________________
_________________________________________________________________
Report completed by: ________________________________________________
University Employee reporting incident; ____________________________________
Title: ________________________ Date Reported:_______________
Send copies within 24 hours to:
James Watson, University Counsel
Dave Young, Treasury, Tax, & Risk Management Svcs.
Dennis Baden, Occupational Health & Safety Services
Campus Environment & Operations
Occupational Health and Safety Bldg *
Kent, Ohio 44242-0001
Phone: (330)672-9565 * Fax: (330)672-9561Updated 6/4/09
