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*

UW StudentIMA MemberGuestRec EmployeeOther
Activity/Sport*
Exact Location*
Program:*

General IMA UseIntramuralsClimbingAquaticsGroup FitnessPersonal TrainingRec ClubsSkills ClassesGolf RangeWACUWild FieldOther
- INJURY INFORMATION
  
  Please fill out all entries with as much detail as possible.
- Description of Injury*
  Report all work-related injuries to your supervisor asap.
- Part of Body Injured*
  
  FaceTorsoHeadNeckBackShoulderArmElbowWristHandFingerHipKneeLegAnkleFootToeSudden Illness
- Description of First Aid provided*
  Please include Location of Care.
- Medic Unit Summoned?*
  
  YesNo
- First Aid provided by:
- First Aid Provider Name*
  
  First NameLast Name
- Phone Number*
  
  Area CodePhone Number
- E-mail*
- INCIDENT INFORMATION
  
  Please fill out all entries with as much detail as possible.
- IncidentNear-Miss
- Detailed Description of Incident:*
  If the incident is a theft, please refer to Rec's Theft Form instead.
- University Police called?*
  
  YesNo
- NEAR-MISS INFO
  
  Please fill out with as much detail as possible.
- Fill out a Near-Miss form if there was potential for an injury/incident to occurdue to error or mishap, but did not.
  
  Example: A climber grabbed a hold on the wall which fell off, but the climber did not fall and/or did not get injured.
  
  Example: While someone was using a weight machine, the weight cord snapped and could have pinned the person to the machine.
- Detailed Description of Near-Miss and Actions Taken:*
- DEPARTURE STATUS
- How did individual leave care/program/building:*
  
  Left with Medic UnitLeft with UW PoliceLeft with OthersLeft on Own
- Departure Status:*
  
  1. Left with medic unit2. Left with UW Police3. Left on own4. Left with others
- Explain how individual left, and injury status if applicable:
- 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

INJURY INFORMATION

INCIDENT INFORMATION

NEAR-MISS INFO

DEPARTURE STATUS

Paper form completed by:

Online form completed by: