APPLY! REQUEST

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. For unknown information, enter "Not Available" and provide a follow-up email with required information.     = 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

General Information about Injured Person

If UNA ID# is not available, provide other form of ID.
If Applicable
If injured is a UNA student
Not UNA Box
If Injured is a UNA Student

Emergency Contact Information

Incident Information

Include area code
Cut, puncture, burns, etc.
Body part, left or right

Medical Treatment Information

City, State

Validation of Incident or Accident Report Submission

Person submitting the 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 .