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Incident Report Form

You must fill out the accident/incident form completely. You may print out a copy for your records. You may be contacted by a member of Risk Management for further information if needed.

	REPORTING PARTY
	First Name: Last Name: Phone: Email:

	INJURED PARTY
	First Name: Last Name: Phone: Email: Status: Select one ... Faculty/Staff Student Alumni/Visitor/Parent Other At time of injury, was injured party functioning as a Baylor employee (includes student workers)? YES NO

	EMPLOYEE INJURY
	Injured Employee Baylor ID Number: Department/Unit: Supervisor Name: Supervisor Phone: Supervisor Email: When did supervisor learn of this injury? Has injured employee lost time from work due to this injury? YES NO Has injured employee returned to work following this injury? YES NO If yes, when did the lost time begin? If yes, when did the employee return?

	INJURY INFORMATION
	Date: Time: AM PM Campus Location: Provide full details of how injury/accident occurred: What part of the body was injured? Did injured party receive first aid? YES NO If yes, administered by who? Were there any witnesses to the accident? YES NO If yes, please provide names and contact information: Did injured party see a doctor or go to a hospital for treatment? YES NO If yes, please list provider's name and contact information: If seen by doctor or hospital, what type of treatment was received?

	SUBMIT
	Injured Party: If you are the injured party, please read the following statement carefully and indicate your agreement below. I hereby certify that all the above statements are true. I hereby authorize all doctors presently involved or who may become involved in consultation and/or treatment of me for the above-named accident injury to release all information regarding said accident/injury to Baylor University. Further, I hereby authorize any party receiving medical information regarding the above accident/injury to release such information to Baylor University. I AGREE