Office of Risk Management

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Incident Reporting Form

DO NOT use this form to report workers compensation injuries. This form may be used to report any other type of incident.

In the event of an incident involving serious injury, please return to our first page and page someone for an immediate response.

Fields in bold (and with an *) are required for the form to be processed. Please note older versions of Netscape (before 6.0) may not correctly display the form.

Your name* Your telephone #*
Your cell phone # Pager
Your email address Your address
(Campus address, if applicable)
Date and time of incident* If this occurred on campus...
Location*
Be as specific as possible		 Description of accident*
Be as complete as possible
If a policeman was there:
Department and case #
(if known)		 Injuries?
If an IU vehicle(s) was involved
please list their numbers		 Witness names
and contact information
(telephone, address),
if any