Recreation - Injury/Incident/Near-Miss Report

INJURY / INCIDENT/NEAR-MISS REPORT
Nature of Report:
Nature of Report (select all that apply)*

InjuryIncidentNear-Miss
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*

StudentRecreation MemberGuestOther
Activity/Sport*
Exact Location*
Category*

General IMA UseIntramuralsClimbingAquaticsGroup FitnessPersonal TrainingRec ClubsSkills ClassesGolf RangeWACUWild FieldOther

Incident
INCIDENT INFO: PLEASE FILL OUT COMPLETELY
IncidentNear-Miss
Detailed Description of Incident:*
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 with UW Police3. Left on own4. 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:

Required if a paper form was filled out
Paper form completed by:

First NameLast Name
Phone

Area CodePhone Number
E-mail
Date

MonthDayYear
Online form completed by:

Must be completed within 24 hours
Online form completed by:*

First NameLast Name
E-mail*
Enter the message as it's shown*
Supervisor Comments (Optional)
Supervisor Comments by:

First NameLast Name
Should be Empty:

PERSONAL INFORMATION