Report type Please select... I'm reporting for myself I'm reporting on behalf of someone else

Your classification Please select... Baylor Faculty, Staff, or Baylor Student Employee Baylor Student Visitor

Your employment classification Please select... Faculty Staff Student Employee

Your department

Your job title

Your supervisor

Supervisor email

Your employment status Please select... Full time Part time Temporary

Your gender Please select... Male Female I prefer not to answer

First name

Last name

Email

Home mailing address

City

State Please select... AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS FM GU MH MP PW PR VI AE AA AP Other

Zip code

Your mobile phone

Office phone(optional)

Classification of Injured/Ill Please select... Faculty Staff Student Employee Student Visitor Other

Classification of Injured/Ill (other)

Are you reporting on behalf of another Baylor employee? Please select... Yes No

Department of Injured/Ill

Job title of Injured/Ill

Supervisor name of Injured/Ill

Supervisor email for Injured/Ill

Employment status of Injured/Ill Please select... Full time Part time Temporary Not a Baylor Employee

Gender of Injured/Ill Please select... Male Female I prefer not to answer

First Name of Injured/Ill First name of the individual on whose behalf you're reporting.

Last Name of Injured/Ill Last name of the individual on whose behalf you're reporting.

Baylor ID# of Injured/Ill Please enter the 9-digit Baylor ID# of the injured/ill person on whose behalf you are reporting, if known.

Email of Injured/Ill Email of the individual on whose behalf you're reporting, if known.

Primary phone of Injured/Ill Phone number of the individual on whose behalf you're reporting, if known.