Incident Report Form

Supervisors or cost center heads should complete this form for accidents or incidents involving injury or potential injury to students or visitors on campus or during University-related activities. (Do not use this form for referring a student to the CARE Team.)

DIRECTIONS:
Complete this form within 24 hours and click the "submit" button.    = required field
The report will be submitted electronically to the Office of the Vice President for Student Affairs,  the Office of the Vice President for Business & Financial Affairs, and other campus offices as appropriate.
You may print a copy before submitting. A copy of the report will be emailed to you to confirm receipt.
﻿You cannot save data typed into this form.
Instructions for submitting supplemental documents, photographs, or images will be given in the confirmation statement when the incident report form has been submitted.

- indicates required field

Status of Injured Person

Student

Visitor

If injured person is a UNA student enter UNA ID

Title

First Name

Middle Name

Last Name

Suffix If Applicable

Date of Birth

Age of Injured Person

UNA Box Number If injured is a UNA student

Injured Persons Local Street Address Not UNA Box

Academic Classification If Injured is a UNA Student

Full Name of parent or guardian or other emergency contact

Relationship

Phone number of parent or guardian or other emergency contact

Date of Incident

Time of Incident

Location of Incident

Names and phone numbers of witnesses to the incident Include area code

Name of Event or Activity

Describe what happened

Nature of Injury Cut, puncture, burns, etc

Location of Injury Body part, left or right

Did the injured person go to the UNA Health Center?

Yes

Did the injured person go to a medical facility or physician?

Yes

Name of treating physician

Address of treating physician

Name of medical facility

Address of medical facility

Treatment

Was the injured person admitted to the hospital?

Yes

If yes, date of admission

Name of hospital where injured person was admitted

Location of hospitalCity, State

Name of supervisor or cost center head Person submitting the report

Email address of supervisor or cost center head

Date of incident report

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

Thank you for submitting information about this incident.

If you need to submit supplemental documents, drawings, or photographs, you may send them as PDF, JPEG, or Word format. The documents and email should only be submitted by the supervisor/cost center head. Be sure to include the name of the victim. Attach to an email and send to kmford@una.edu .

About UNA

Work with UNA

Safety & Wellness

Student Resources

University of North Alabama

Incident Report Form

General Information about Injured Person

Emergency Contact Information

Incident Information

Medical Treatment Information

Validation of Incident or Accident Report Submission