Incident Report • CampusOptics

Please fax or send completed form within 24 to 48 business hours to Environmental Health & Safety office at (817) 272-2144 or Box 19257, 500 Summit Avenue, Arlington, Texas 76019. Please retain copy of completed form for your records. For questions, please contact our office at (817) 272-2185.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Reporter Info (Continued)

Reported by Department

Contact Information for Person Involved in Incident

Name (Last, First, M.I.) of person involved in incident

Sex

Student or Visitor

UT EID No. (Students Only)

Nature of Visit (Visitors Only)

Date of Birth

Address (Include City & State)

Phone Number

Injury/Illness Description

Injury or Illness

Date and Time of Injury/Illness

Location

Room Number (If Applicable)

Nature of Injury/Illness

Part of Body Injured

Part of Body Exposed

Name of Chemical

Detailed Description

Was Police or EMS called?

Was person transported to hospital?

Was person transported to Student Health Center (SHC)?

Witness Information

Witness 1 Name (Last, First, M.I.)

Witness 1 Date

Witness 1 Address or Department

Witness 1 Phone Number

Witness 2 Name (Last, First, M.I.)

Witness 2 Date

Witness 2 Address or Department

Witness 2 Phone Number

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.