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 NameLast Name
Date and time when incident occurred:*

MonthDayYear
Date
Hour MinutesAM/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?*

YESNO
Was appropriate PPE worn?*

YESNO
Incident Reported By:*

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

First NameLast 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 NameLast Name
Date of follow-up communication

MonthDayYear
Date
Comments on Follow up communication:
Should be Empty: