Recreation - Injury/Incident/Near-Miss Report

INJURY / INCIDENT/NEAR-MISS REPORT
Nature of Report:*
Date of Occurence*

MonthDayYearHourMinutesAM/PM Option
PERSONAL INFORMATION
Name*

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
UW ID #
Date of Birth

MonthDayYear
Classification*

StudentMemberGuest
Activity/Sport*
Exact Location*
Category*

AquaticsClimbingFitness/DanceIntramuralsMindfulnessOpen RecreationPersonal TrainingRec ClubsSkills ClassUWildOther
INJURY INFO: PLEASE FILL OUT COMPLETELY
Description of Injury*
Report all work-related injuries to your supervisor asap.
Part of Body Injured

FaceTorsoHeadNeckBackShoulderArmElbowWristHandFingerHipKneeLegAnkleFootToe
Description of First Aid provided
Medic Unit Summoned?

YesNo
First Aid provided by:
First Aid Provider Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
INCIDENT/NEAR-MISS INFO: PLEASE FILL OUT COMPLETELY
*

IncidentNear-Miss
Detailed Description of Incident or Near-Miss:*
If the incident is a theft please refer to Rec's Theft Form.
University Police called?

YesNo
Departure Status:*

1. Left with medic unit2. Left on own3. Left with others
Explain Departure Status:
Primary Witness

First NameLast Name
Phone

Area CodePhone Number
E-mail
Secondary Witness

First NameLast Name
Phone

Area CodePhone Number
E-mail
Paper form completed by:
Paper form completed by:*

First NameLast Name
Phone

Area CodePhone Number
E-mail*
Date*

MonthDayYear
Online form completed by:

OFFICE USE ONLY
Online form completed by:*

First NameLast Name
E-mail*
Enter the message as it's shown*
Should be Empty:

PERSONAL INFORMATION

Paper form completed by:

Online form completed by: