Minor Injury Report Form

Department of Chemistry and Biochemistry
Minor Injury Report

To report an incident, please provide the following information:
If the injury required outside medical attention, do NOT use this minor accident form. Report an injury that required outside assistance to Campus Police at 410-455-5555.
Injured Party Information:
Full Name *

First Name Last Name
Date and time when incident occurred: *

Month Day Year
Date
Hour Minutes AM/PM Option
Phone Number *
Email *
example@example.com
Injury Details:
Incident Location (Please provide specific details): *
Incident details: Include specific injury area and cause: *
What first aid was provided? *
Was appropriate PPE supplied? *

YES NO
Was appropriate PPE worn? *

YES NO
Incident Reported By: *

First Name Last Name
Further Comments:
Witness Information (if Applicable):
Name

First Name Last Name
Email
example@example.com
Follow-UP:

A staff memebr will contact you in few days to confirm everything is okay:
Faculty/Staff Name:

First Name Last Name
Date of follow-up communication

Month Day Year
Date
Comments on Follow up communication:
Should be Empty: