Scribd
Upload
26 views

Incident/Injury Report Form

Uploaded by

Auuhotelar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
26 views

Incident/Injury Report Form

Uploaded by

Auuhotelar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

The Texas A&M University System

INCIDENT/INJURY System Risk Management


301 Tarrow St. 5th Floor
College Station, Texas 77840
Campus Mail Stop 1262
REPORT FORM Phone Number: (979) 458-6330
Fax Number: (979) 458-6247
Please PRINT or TYPE

TIME Date/Time of Incident Location: Street, City, Building, Room No. (Be specific)
& PLACE
Type of Premises Conditions Police Report
Which Agency:
Construction Site Parking Lot Dry Uneven Surface
PREMISES Hallway Sidewalk Icy Other:
CONDITION Lobby/Entrance Stairway Snowy Report #
Office Street Wet
Other: Not Reported

Describe What Happened (Use additional sheet if necessary):

INCIDENT
DESCRIPTION

Name Age Phone No.


INJURED
PERSON Address Social Security Number:

Injury - Describe the type, severity, and body part involved


DESCRIPTION
OF INJURY
Was Medical Treatment Given? Yes No Will seek treatment later
&
MEDICAL
Name of Medical Facility/Doctor Transported by Ambulance
TREATMENT
Transported by Other:

Owner’s Name Address Phone #

PROPERTY Describe the property and the damage:


DAMAGE

Name Address Phone #


WITNESSES
Give the Full Name
and Address of
Each
Witness

Name/Title of the Employee


completing this Report Phone #:

System Member: Department: Date:

Updated 5.15.18
INSTRUCTIONS FOR COMPLETION OF INCIDENT/INJURY/PROPERTY DAMAGE REPORT

1) ASSIST THE INDIVIDUAL AND CALL 911 IF EMERGENCY MEDICAL ASSISTANCE IS NEEDED.

REPORT ALL SERIOUS INJURIES AND SAFETY HAZARDS TO CAMPUS OR LOCAL POLICE
DEPARTMENT (if applicable) AND SYSTEM RISK MANAGEMENT

2) THE TAMUS EMPLOYEE INVOLVED IN, OBSERVING OR DISCOVERING THE


INJURY/PROPERTY DAMAGE IS RESPONSIBLE FOR COMPLETING THIS REPORT.

RELATE ONLY TO THE FACTS ON THIS FORM - DO NOT GIVE THIS FORM TO THE INJURED
PERSON TO COMPLETE.

DO NOT CONTACT THE INJURED PERSON LATER TO OBTAIN INFORMATION

BE OBSERVANT - ATTEMPT TO GET AS MUCH INFORMATION AS POSSIBLE AT THE TIME OF


THE INCIDENT.

3) DO NOT DISCUSS THE ACCIDENT WITH ANYONE - EXCEPT THE POLICE AUTHORITY AND
SYSTEM RISK MANAGEMENT

SYSTEM RISK MANAGEMENT WILL COORDINATE THE INVESTIGATION AND RESOLUTION


OF CLAIMS. REFER ALL QUESTIONS REGARDING STATUS OF CLAIMS TO SYSTEM RISK
MANAGEMENT.

4) AFTER COMPLETION - FORWARD THIS FORM TO:


System Risk Management
THE TEXAS A&M UNIVERSITY SYSTEM
301 Tarrow St. 5th Floor
COLLEGE STATION, TEXAS 77840
Campus Mailstop 1262
OR
FAX TO: (979) 458-6247
OR
EMAIL TO: [email protected]

Updated 5.15.18

You might also like