Report an Injury

Please use this form to notify Risk Management about any injury you sustain on campus. The information you provide will remain confidential.

Please don't fill out this input box.

Name:*

ID Number:

Age:*

Gender:*

Email:*

Address:

Phone Number:*

Location where the injury occurred:*

Date and time of injury:*

Status at the time of accident:*

On duty as an employee at the time of accident?*

Please provide a description of your injury: *

Which side of the body was injured?*

Was First-Aid administered?*

Describe (Ice, Bandage, Pain Reliever, etc.)

By whom?

Did you go to the University Health Center? (Southern students and employees)*

Did you visit a doctor?*

If so, doctor's name:

Did you visit an emergency room?*

If so, where:

Who was this incident reported to? (List name and department)*

Witness name:*

Witness phone number:*

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