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.

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:*