Injury or Illness Report

This form will be used when the University Police are called to an injury or illness on Campus Property. Please fill out the form with as much detail as available and submit as soon as possible.

- indicates required field

Please enter the assigned case number and other pertinent information for this incident.

Injury or Illness Incident Case Number

Date of Incident

Time of Incident

Location of Incident (Area, Building, Room name or number, etc.)

Name of injured or ill person

Age of injured or ill person

Contact information (Home Address, Phone Number)

Status as related to UNA affiliation

Describe the method of the injury or illness. Be specific.

Transported from Scene by Emergency Services?

If Transported, to where?

Name and Badge Number of reporting Officer

Please make sure all required fields have been filled out correctly.

Submission received!

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Injury or Illness Report

INFORMATION RELATING TO INCIDENT