MSU Incident Reporting Form

MSU Incident Reporting Form
PLEASE FILL IN ALL REQUIRED FIELDS. IF A FIELD DOES NOT APPLY, PLEASE USE 'N/A'.
Person completing form:

First NameLast Name
Phone:
include area codeFormat: (000) 000-0000.
Date incident occurred:

MonthDayYear
Time:

Hour Minutes

AM/PM Option
Date employer was notified:

MonthDayYear
Who notified?
PART A: COMPLETE THIS PART OF FORM FOR ALL INCIDENTS
Injured/Involved person:

First NameLast Name
EMPLID:
DOB

MonthDayYear
Local address (include city, state, zip code):

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
include area codeFormat: (000) 000-0000.
FemaleMale
Email:
example@example.com
Name of parent/guardian (if under 18):
Employee/Student EmployeeStudent (non-employee)Visitor
YesNo
Employing Department:
Supervisor:
Supervisor's email:
example@example.com
Phone:
include area codeFormat: (000) 000-0000.
Job title of injured person:
Address, building name, or location of incident:
InsideOutside
ClearRainingSnowingOther
Describe conditions if "other" selected
Description of incident (please attach additional sheet if more room is needed):
No apparent injury or illness (Skip to Part C)Slight injury or illness NOT requiring professional medical attentionInjury or illness requiring professional medical attention (complete Part B)
Body part(s) injured:
Time lost from work (number of days and/or hours):
Witness(es) to incident: Name:
Phone:
include area codeFormat: (000) 000-0000.
PART B: COMPLETE THIS PART ONLY IF INJURY OR ILLNESS REQUIRED MEDICAL ATTENTION
Medical facility:
Physician:
Date of initial treatment:

MonthDayYear
Description of medical treatment(s):
PART C: COMPLETE THIS PART ONLY IF INCIDENT INVOLVED LOSS OR DAMAGE TO PROPERTY
Property/Vehicle/Equipment Loss or Damage: What was Damaged or lost?
Owner of damaged or lost property:
YesNo
Address:
Phone:
include area codeFormat: (000) 000-0000.
Where can the damaged property be seen? (Attach photo if possible)
File Upload

Limit 2 files, jpg, jpeg, png, gif only
Cancelof
The above information on this report is accurate based on my knowledge of the incident.
Signature
Date

MonthDayYear
Date
NOTIFY THE OFFICE OF SAFETY & SECURITY IMMEDIATELY (WITHIN 24 HOURS) FOR ALL INCIDENTS RESULTING IN PERSONAL INJURY
Safety & Security, 500 University Ave W, Minot, ND 58707
Phone: 701-858-4016 Fax: 701-858-3002 Email: a.livingston@minotstateu.edu
Should be Empty:

MSU Incident Reporting Form

PART A: COMPLETE THIS PART OF FORM FOR ALL INCIDENTS

PART B: COMPLETE THIS PART ONLY IF INJURY OR ILLNESS REQUIRED MEDICAL ATTENTION

PART C: COMPLETE THIS PART ONLY IF INCIDENT INVOLVED LOSS OR DAMAGE TO PROPERTY