Recreation - Injury/Incident/Near-Miss Report

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

Month Day Year Hour Minutes AM/PM Option
PERSONAL INFORMATION
Name *

First Name Last Name
Phone Number

Area Code Phone Number
E-mail
UW ID #
Date of Birth

Month Day Year
Classification *

Student Member Guest
Activity/Sport *
Exact Location *
Category *

Aquatics Climbing Fitness/Dance Intramurals Mindfulness Open Recreation Personal Training Rec Clubs Skills Class UWild Other
INJURY INFO: PLEASE FILL OUT COMPLETELY
Description of Injury *
Report all work-related injuries to your supervisor asap.
Part of Body Injured

Face Torso Head Neck Back Shoulder Arm Elbow Wrist Hand Finger Hip Knee Leg Ankle Foot Toe
Description of First Aid provided
Medic Unit Summoned?

Yes No
First Aid provided by:
First Aid Provider Name

First Name Last Name
Phone Number

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

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

Yes No
Departure Status: *

1. Left with medic unit 2. Left on own 3. Left with others
Explain Departure Status:
Primary Witness

First Name Last Name
Phone

Area Code Phone Number
E-mail
Secondary Witness

First Name Last Name
Phone

Area Code Phone Number
E-mail
Paper form completed by:
Paper form completed by: *

First Name Last Name
Phone

Area Code Phone Number
E-mail *
Date *

Month Day Year
Online form completed by:

OFFICE USE ONLY
Online form completed by: *

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

PERSONAL INFORMATION

Paper form completed by:

Online form completed by: